VR3110 Surgery and Treatment Recommendations



Texas Workforce CommissionVocational Rehabilitation ServicesSurgery and Treatment Recommendations FORMTEXT ? FORMTEXT ?The information requested is necessary to help counselors plan for rehabilitation services for the person named. List the recommendation for a single date of service. If the recommendation is for bilateral or staged surgeries on multiple dates of service, list the time range and number of separate procedures expected. FORMTEXT ?Patient Information FORMTEXT ?Name: FORMTEXT ?????Date of birth: FORMTEXT ?????Case ID: FORMTEXT ?????Telephone number:( FORMTEXT ???) FORMTEXT ?????Reported Disability: FORMTEXT ?????Reason for referral: FORMTEXT ?????Return Information FORMTEXT ?Return Report to: FORMTEXT ?????Telephone number:( FORMTEXT ???) FORMTEXT ?????Address: FORMTEXT ?????FAX number:( FORMTEXT ???) FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code FORMTEXT ?????Completed by Physician FORMTEXT ?The recommendation(s) on this form is only valid 6 months from the date of physician’s signature. FORMTEXT ?Diagnosis with ICD 10 codes: FORMTEXT ?????Type of treatment procedure(s) recommended (right, left, bilateral, or spinal levels). Include CPT codes and your usual fees: FORMTEXT ?????Type of implants recommended: FORMTEXT ?????Note: TWC does not provide additional payment for use of a robotic surgical system. Advance approval is required for codes ending in 99 or T. FORMTEXT ? FORMTEXT ?Can procedure be performed as day surgery? FORMCHECKBOX Yes FORMCHECKBOX No Complete name of hospital or facility to be used: FORMTEXT ?????Number of hospital days: FORMTEXT ?????Will blood be needed? FORMCHECKBOX Yes FORMCHECKBOX NoEstimated pints needed: FORMTEXT ?????Number of office visits required:Pre-operative: FORMTEXT ?????Post-operative: FORMTEXT ?????Pre-operative diagnostic tests, injections or vaccinations required (include codes): FORMTEXT ?????Anticipated Ancillary Services FORMTEXT ? FORMTEXT ?Name of anesthesiologist or group: FORMTEXT ?????Name of radiology group (if required): FORMTEXT ?????Name of assistant surgeon (if required): FORMTEXT ?????Name of laboratory and/or pathology group (if required): FORMTEXT ?????Surgical monitoring required? FORMCHECKBOX Yes FORMCHECKBOX NoName or Group: FORMTEXT ?????Will hospitalists be used? FORMCHECKBOX Yes FORMCHECKBOX NoName or Group FORMTEXT ?????Post-Surgical Rehabilitation FORMTEXT ? FORMTEXT ?Type of rehabilitation required: FORMCHECKBOX Inpatient FORMCHECKBOX Outpatient FORMCHECKBOX Home HealthTherapy type: FORMCHECKBOX PT FORMCHECKBOX OT FORMCHECKBOX ST Other: FORMTEXT ?????Length of therapy time: FORMTEXT ?????Durable Medical Equipment Needs (DMEs) FORMTEXT ?DME:Duration of Use: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employment FORMTEXT ?Will the recommended treatment or surgery improve the patient’s functional abilities enough that he or she can work after completion of recommended treatment? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate what level of work this patient is expected to be able to perform after the completion of recommended treatment: FORMCHECKBOX sedentary, FORMCHECKBOX light, FORMCHECKBOX medium, or FORMCHECKBOX heavyEstimated time to return to work after completion of recommended treatment: FORMTEXT ?????Physician Information and Signature FORMTEXT ?All information must be treated as confidential.Examinee has the legal right to see this report when the examinee requests. FORMTEXT ? 0 Type or print the physician and group/clinic name: FORMTEXT ?????Date of examination: FORMTEXT ?????Telephone number:( FORMTEXT ???) FORMTEXT ?????FAX number:( FORMTEXT ???) FORMTEXT ?????Physician’s address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Examining physician’s signature:X FORMTEXT ?????Date: FORMTEXT ????? ................
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