Ptotatmnrortho091415 2025

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The document is a Medical Necessity Review Form from American Specialty Health (ASH) designed for the submission of requests related to physical therapy (PT), occupational therapy (OT), and athletic training (AT) services for orthopedic conditions. It includes sections for patient and provider information, details on services rendered, evaluations requested, and pertinent medical history. The form aims to facilitate the review process for determining the necessity of continued care.

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Click ‘Get Form’ to open the ptotatmnrortho091415 in the editor.
Begin by entering the patient’s name, including last name, first name, and initial. Ensure accuracy as this information is crucial for identification.
Fill in the subscriber's details, including their ID number and health plan information. Specify if the case is work-related or auto-related.
Provide treating practitioner information, including their name, address, and contact details. This section is vital for communication regarding care.
In the services already rendered section, check the appropriate boxes for PT, OT, or AT services provided and include relevant dates and CPT codes.
Complete the services submitting for review section by indicating the estimated discharge date and any evaluations being requested during that period.
Finally, review all entries for accuracy before submitting your form to ensure a smooth processing experience.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (58 Votes)
2015	4 Satisfied (49 Votes)

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