Out Patient Rehabilitation Authorization Request DATE - Washington
Out Patient Rehabilitation
Authorization Request
DATE
PROVIDER INFORMATION
PROVIDER NAME
BILLING PROVIDER NPI
TELEPHONE NUMBER
FAX NUMBER
CLIENT INFORMATION
CLIENT NAME
PROVIDERONE CLIENT ID
ADDITIONAL THERAPY REQUEST INFORMATION
PT ¨C Number of units requested:
Number of units used this year:
OT ¨C Number of units requested:
Number of units used this year:
ST ¨C Number of units requested:
Number of units used this year:
(1 unit = 15 minutes)
(1 unit = 15 minutes)
(1 unit = 1 visit, no matter the length of the visit)
CPT PROCEDURE CODES
ICD 9 Dx
Description
ICD 9 Dx
Description
PLACE OF SERVICE:
Outpatient Hospital
Therapy Office
CLIENT¡¯S MEDICAL HISTORY
DATE OF INJURY OR ILLNESS
DATE OF SURGERY AND DESCRIPTION:
What prevented the client from reaching the therapy goals with the treatment provided to date?
List the functional improvement goals for the additional therapy requested:
Please attach the following required information to this request:
? Copy of prescription
? Letter with clinical justification
? Most recent therapy evaluation
? Therapy progress notes
Please fill out this form electronically and fax or mail to:
Medical Request Coordinator
Health Care Authority
PO Box 45535, Olympia WA 98504-5535
Telephone: 1-800-562-3022
Fax: 1-866-668-1214
A typed and completed General Authorization for Information form (13-835) must be attached to your request.
13-786 (REV. 8/2011)
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