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Lymphedema Program: PT OT Therapy Intake Form - eviCore

Lymphedema Program: PT OT Therapy Intake Form - eviCore 2025

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The document is a Lymphedema Program intake form for physical and occupational therapy requests. It outlines the necessary information required for non-urgent lymphedema treatment requests, including patient and provider details, diagnosis codes, treatment areas, lymphedema stages, and administrative requirements. The form emphasizes the importance of complete information to avoid delays in authorization and specifies that urgent requests must be made by phone.

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