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Physical and Occupational Therapy Authorization Request Form

Physical and Occupational Therapy Authorization Request Form 2026

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The document is a Prior Authorization Request Form for Physical Therapy and Occupational Therapy services under Utah Medicaid. It outlines the necessary member and provider information required for submission, including details about the type of therapy requested, dates of service, number of visits, and Medicaid program coverage options. The form specifies that prior authorization is not needed for the first 20 visits per year for each therapy type but is required for additional visits. It also emphasizes that prior authorization does not guarantee reimbursement and that all other Medicaid requirements must be met.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Date of submission' at the top of the form. This is essential for tracking your request.
Indicate if this is a retroactive request by selecting 'Yes' or 'No'. If 'Yes', provide a reason in the additional information section.
Specify if this request is a change to a previous prior authorization by selecting 'Yes' or 'No'. If 'Yes', include the previous PA number.
Select the type of therapy requested: Physical Therapy, Occupational Therapy, or Both.
Fill in the requested dates of service, ensuring you enter both start and end dates.
Enter the requested number of visits based on your treatment plan.
Choose your Medicaid Program Coverage: Traditional or Non-Traditional, based on your eligibility.
Answer whether physical and occupational therapy limitations have been met by selecting 'Yes' or 'No'.
Complete provider information including name, NPI number, address, phone number, and fax number.

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See more Physical and Occupational Therapy Authorization Request Form versions

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (44 Votes)
2019	4.2 Satisfied (57 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can you bill OT and PT at the same time?

For example, if an OT and a PT co-treat from 10:30 AM to 11:30 AM, and the OT works on toileting strategies while the PT simultaneously addresses safe transfers, both clinicians could bill for that entire hour, provided they show proof of providing different treatments with separate end goals.

What is authorization request form?

What is an Authorization Form? An authorization form is a document that is duly endorsed by an individual or organisation which grants permission to another individual or organisation to proceed with certain actions. It is often used to grant permission to carry out a specific action for a fixed period of time.

Can 97110 and 97150 be billed together?

While CPT 97150 is a standalone code, it is often billed alongside other therapy-related codes for comprehensive treatment plans. These include: 97110: Therapeutic exercises (one-on-one)

How to get prior authorization for physical therapy?

Getting Prior Authorization for Physical Therapy Contact your patients insurance company. Find the phone number on their insurance card. Request a prior authorization form or number. The insurance company will likely tell you what information they need. Gather required documents. Submit the request.

Does Medicare allow PT and OT on the same day?

0:10 4:38 And pt and ot can bill the same code on the same. Day. Where this misconception. Comes from that otMoreAnd pt and ot can bill the same code on the same. Day. Where this misconception. Comes from that ot and pt cannot see the patient on the same day is this issue with duplicative.

Can I do PT and OT at the same time?

The short answer is yes! OT and PT can co-treat in acute care. However whether or not both disciplines can bill for their services during a co-treat is a different story.

Physical and Occupational Therapy Authorization Request Form 2026

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How to use or fill out Physical and Occupational Therapy Authorization Request Form