COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ATTACHMENT A DATE AUR CERTIFICATION NUMBER INFORMATION FOR CERTIFICATION REQUEST PSR 1st REQUEST 1. RECIPIENT NUMBER DRG ADD. INFO SETTING CHANGE EXTENSION REQUEST DEPT. REVIEWER RECIPIENT/PROVIDER INFORMATION 2. RECIPIENT NAME 3. BIRTHDATE 4. FACILITY PA PROMISeTM PROVIDER NUMBER (13 digits) 5. FACILITY NAME 6. PRACTITIONER PA PROMISeTM PROVIDER NUMBER (13 digits) 7. PRACTITIONER NAME 8. LATE PICKUP ELIG. DATE 9. DATE FACILITY FIRST NOTIFIED OF ELIG. AND HOW NOTIFIED 10. PRACTITIONER LICENSE # 11. PERSON MAKING REQUEST 12. TELEPHONE NUMBER OF PERSON MAKING REQUEST ADMISSION INFORMATION 13. A. ADMISSION DATE 13. B. ADMISSION CLASS (EMERGENCY OR URGENT) / ADMITTED TO WHAT FLOOR OR UNIT? 14. ADMITTING DIAGNOSIS CODES A. B. 15. SECONDARY DIAGNOSIS CODES C. D. 16. ASC/SPU ONLY - HCPCS PROCEDURE CODE (5 digits) ICD-CM CODE DESCRIPTIONS A. B. ICD-CM CODE DESCRIPTIONS C. D. 17. INPATIENT ONLY - ICD PROCEDURE CODE 18. PROCEDURE PERFORMED 19. NUMBER OF EXTENDED TREATMENTS REQUESTED (ASC/SPU ONLY - MAXIMUM OF 10) 20. WHAT ARE THE INDICATIONS FOR SURGERY/TREATMENT? DESCRIBE ANY PATHOLOGY AND JUSTIFICATION FOR SETTING 21. DESCRIBE ANY ATTEMPTS THAT HAVE BEEN MADE TO TREAT THIS CONDITION ON AN OUTPATIENT BASIS 22. ER DATE AND TIME 23. ADMISSION DATE 24. DISCHARGE DATE IF APPLICABLE PRIOR ADMISSION INFORMATION 25. PRIOR ADMISSION DATE / PA # WITH OUTCOME 26. PRIOR ADMISSION DISCHARGE DATE 27. TRANSFER INFORMATION / PROMISeTM FACILITY NUMBER OF TRANSFERRING FACILITY American LegalNet, Inc. www.FormsWorkFlow.com MA 341 10/15