Outpatient Physical, Occupational & Speech Therapy Pre 2026

1. Click ‘Get Form’ to open the Outpatient Physical, Occupational & Speech Therapy Pre-Authorization Request Form in the editor.
2. Begin by filling out the Patient Information section. Enter the Member ID, Group number, Member name, Date of birth, and contact details including address and phone number.
3. Next, move to the Servicing Provider Information. Input the contact person's name and phone number, along with the servicing provider's name, ID/NPI number, address, city/state/zip code, and phone/fax numbers.
4. In the Ordering Provider Information section, indicate if the Servicing Provider participates with the local Blue Plan. Fill in the contact person's details and provide information for the ordering provider similar to previous sections.
5. For Services Requested, specify the date range for authorization requests, requested number of visits, frequency of visits, primary diagnosis code and description, as well as any secondary diagnosis codes and descriptions.
6. Finally, ensure you have all required documentation ready to submit alongside this form: Initial Evaluation, Specific & Measurable Treatment Goals, and Progress Notes.

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