Lymphedema Program: PT OT Therapy Intake Form - eviCore 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Submission' at the top of the form. This helps track your request.
3. Fill in the 'Patient' section with the patient's first name, last name, date of birth, gender, and contact information including home and cell phone numbers.
4. In the 'Provider' section, input the provider's details such as their name, specialty, TIN, NPI, and contact information.
5. Complete the 'Administrative' section by detailing diagnoses codes and descriptions along with relevant dates for treatment requests.
6. In the 'Clinical' section, indicate the cause of lymphedema and specify treatment areas affected. Ensure to select a lymphedema stage that accurately describes your patient.
7. If applicable, provide volume measurements for affected areas and indicate whether a compression garment has been received.

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