Physician Order Request Form For Occupational Therapy 2026

1. Click ‘Get Form’ to open the Physician Order Request Form in the editor.
2. Begin by entering the client's name in the designated field at the top of the form. Ensure accuracy for proper identification.
3. Fill in the medical and treatment diagnosis, client phone number, date of birth, and address. This information is crucial for processing the request.
4. Indicate the onset date of the condition and provide details about primary and secondary insurance, including policy numbers.
5. Complete the physician's information section, including office address, phone number, fax number, email address, and NPI number.
6. Specify which therapy services are needed by checking appropriate boxes under 'This client would benefit from the following therapy services.'
7. In the 'Reason for Request' section, provide a brief explanation of why occupational therapy is necessary.
8. Ensure that both therapist and physician signatures are included at the bottom of the form along with dates before submitting.

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