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Send pt 4 via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out pt 4 form with our platform
- Click ‘Get Form’ to open the pt 4 form in the editor.
- Begin by entering the injured person's details, including their first name, middle initial, last name, and social security number. Ensure all information is typed clearly.
- Fill in the date of injury and time, along with the address where the injury occurred. This section is crucial for accurate record-keeping.
- Indicate whether services were provided under the WCB Preferred Provider Organization (PPO) program by selecting 'Yes' or 'No'.
- Complete sections regarding diagnosis, treatment plans, and any referrals. Be specific about the patient's condition and progress as well as future treatment plans.
- Review all entries for accuracy before signing. The form must be signed by the treating therapist and include their contact information.
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