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Click ‘Get Form’ to open the treatment request medical form in the editor.
Begin by checking the appropriate box at the top of the form to indicate whether this is a new request or a resubmission due to changes in material facts.
Fill in the Employee Information section, including the name, date of injury, date of birth, claim number, and employer details.
Complete the Requesting Physician Information section with your name, practice name, contact details, specialty, and NPI number.
In the Claims Administrator Information section, provide all necessary contact information for the claims administrator.
List each specific requested treatment in the Requested Treatment section. Ensure you include diagnosis, ICD code, service/good requested, and CPT/HCPCS code if known.
Sign and date at the bottom of the form to validate your request before submission.
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(1) Complete RFS form 10-10172. (2) Attach appropriate medical records and care plan to support the request. (3) Have the ordering provider sign and date theRead more
AUTHORIZATION FORM. Request for additional units. Existing Authorization. Units. Standard requests - Determination within 7 calendar days of receipt of request.Read more
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