Outpatient Rehab Form Step 1 of 4 25% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY Name* First Last Error Message Therapy Facility InformationTherapy Facility NPI* Therapy Facility Name* Error Message Therapy Facility Phone #*Therapy Facility Fax #*Ordering MD* Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationType of Service Being Requested*Type of Service Being Requested *Adult/PediChildren with Special NeedsDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890CPT Code(s) (Click + or - at the right to add up to 15 CPT Codes)* Example CPT code: 12345Other Insurance/Treatment InformationOther Insurance/Treatment InformationCOBMVAHas the member received services elsewhere within the last 12 months?*Has the member received services elsewhere within the last 12 months? *YesNoI don't knowWhen was service received?* Where was service received?* Number of Visits Used:*Please enter a number from 0 to 100.Is this request related to a recent or upcoming surgery?*Is this request related to a recent or upcoming surgery? *YesNoIf yes, please attach surgery protocol or MD orders:*Accepted file types: pdf, doc, docx, Max. file size: 5 MB.Upload only PDF or Word DocumentsServices InformationType of Services Being Requested*Type of Services Being Requested *InitialContinuation of ServicesInitial ServicesPlease choose discipline being requested* PT OT ST Please choose one*Please choose one *Evaluation onlyEvaluation & 8 visitsContinuation of ServicesPlease choose discipline being requested* PT OT ST Initial Evaluation Date MM slash DD slash YYYY Number of visits being requested*Please enter a number from 0 to 100.Number of previous authorized visits*Please enter a number from 0 to 100.Number of visits used to date*Please enter a number from 0 to 100.Number of cancelled or no show*Please enter a number from 0 to 100.Please submit this form with initial evaluation and most recent progress notes and /or re-assessment. Submitted documentation should include the following: 1)Frequency & Duration 2)Progress towards goal 3)Home exercise program 4)Modalities of treatmentChildren with Special needs informationRequest to Supplement EI or IEP services for children under 3 years old or is of school age and has a neurodevelopment disorderIs this request for an evaluation only?*Is this request for an evaluation only? *YesNoIf child is <3 years old, please provide information on Early Intervention Received previously Currently receiving Has been referred If child has a neurodevelopment disorder and is of school age, please provide information regarding and IEP Received EI Services previously Currently has IEP Has been referred Services child is currently receiving through Early Intervention or an IEP* None PT OT ST Home Program?*Home Program? *YesNoEstimated time period necessary for supplemented services:*Estimated time period necessary for supplemented services: *1 Month3 MonthsFor PT/OT: How will lack of additional services affect activities of daily living?*For ST: How will lack of additional services affect functional status?* Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 13 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 5 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA