**Authorization DOES NOT GUARANTEE payment as all inpatient stays are reviewed daily for medical necessity and level of care

(1)

MISSOURI CARE LOG SHEET FAX: 866-946-2052

www.missouricare.com

FACILITY NAME: CONTACT NAME:

CONTACT PHONE NUMBER: CONTACT FAX NUMBER: (For Authorization)

IP / OBS ADMIT DATE MEMBER NAME DOB MEDICAID

NUMBER DIAGNOSIS

CODE ADMITTING PHYSICAN

**Notification is required by the NEXT BUSINESS DAY for all observation and inpatient stays.

**Authorization DOES NOT GUARANTEE payment as all inpatient stays are reviewed daily for medical necessity and level of care.

If you do not understand this letter, call us at 1-800-322-6027 for assistance. We can provide an interpreter. Si no entiende esta carta, llamé al 1-800-322-6027 para solicitar asistencia. Podemos conseguirle un intérprete.

MO021729_CAD_FRM_ENG Internal Approved 04262013