Speech Therapy Treatment Request Clinical Worksheet ...

Speech Therapy Treatment Request Clinical Worksheet

Pediatric Developmental

For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. If there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to provide all relevant information may delay the determination. Phone and fax numbers can be found on under the Guidelines and Fax Forms section. You may also log into the provider portal located on the site to submit an authorization request. URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE.

Ordering Provider Patient/Member

First Name: DOB (mm/dd/yyyy ): Street Address: City: Home Phone: Health Plan:

Middle Initial:

Cell Phone: Member ID:

Last Name:

Gender:

Male

Female

Apt #:

State:

Zip:

Primary Contact:

Home Cell

Group ID:

First Name: Primary Specialty: Physician Phone: Address: City: Office Contact: Contact Email:

Last Name:

TIN:

NPI:

Physician Fax: Suite #:

State:

Zip:

Ext:

Facility/Site

First Name: Group/Site Name: Primary Specialty: Site Phone: Address: City:

Last Name:

TIN:

NPI:

Site Fax:

State:

Suite #: Zip:

Diagnosis

Diagnosis, if known or rule out: ICD-10 Codes: Reference/Auth Number (if continued care): Date of last visit:

Start date of this request:

CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient (s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without saving them in any manner.

Page 1 of 3 eviCore healthcare | | 400 Buckwalter Place Blvd ? Bluffton, SC ? 29910 | 800.918.8924

1. Date of - Onset:

Evaluation:

Current findings:

2. Select any of the following which apply:

Member not treated in the last 60 days

Member requires treatment for a different condition

Additional care for same condition treated in the last 60 days

3. What subjective complaints are present?

Apraxia

Stuttering

Auditory comprehension

Articulation/Phonological process

Pragmatics

Expressive communication

Other:

4. What type of testing has been administered?

Standardized

Informal

None

5. If continued care, did you re-test the patient?

Yes No N/A

Standardized test name

Area Tested

Raw Score

Standard Score

% Rank and Age Equivalent yr/mo.

Clinical Information

6. Did you report any standard score that is 85 or greater?

Yes No N/A

If yes , rationale for care:

7. Informal testing and severity rating

Attention/Orientation

WNL

Mild

Moderate

Severe Not tested

Initiation/Follow-through

WNL

Mild

Moderate

Severe Not tested

Problem Solving/Judgment

WNL

Mild

Moderate

Severe Not tested

Memory

WNL

Mild

Moderate

Severe Not tested

Sequencing/Organization

WNL

Mild

Moderate

Severe Not tested

Oral Motor Assessment

WNL

Mild

Moderate

Severe Not tested

8. Provide age equivalents for other areas tested.

Auditory comprehension yr./mo:

Reading comprehension yr./mo:

Expressive communication yr./mo:

Speech production yr./mo:

Page 2 of 3 eviCore healthcare | | 400 Buckwalter Place Blvd ? Bluffton, SC ? 29910 | 800.918.8924

9. Enter a description of short-term goals

Current % function

% change since start

1)

%

%

2)

%

%

3)

%

%

4)

%

%

5)

%

%

10. Are there new functional goals?

Yes

No

If yes, enter a description of the goal and baseline % of function

Baseline % of function

1)

%

2)

%

3)

%

11. Have you given the patient a home mangagement program?

Yes

No

12. Is the patient compliant with the home program?

Yes

No

N/A

If no, explain:

13. Patient was also treated for:

Feeding/Swallowing

Voice Therapy N/A

For a second treatment request, submit an additional form and fax both forms together. Additional information/comments:

Clinical Information

Page 3 of 3 eviCore healthcare | | 400 Buckwalter Place Blvd ? Bluffton, SC ? 29910 | 800.918.8924

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