NIA - Home State Health Physical Medicine Tip Sheet Home State Health and Allwell from Home State He 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name and Evaluation Date at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in the Surgery Date if applicable, followed by the ICD10 codes. You can enter up to four codes in the designated fields.
4. Select the Cause for therapy from options such as Traumatic or Work Related. This helps clarify the patient's condition.
5. Choose the type of service being rendered: Physical Therapy, Occupational Therapy, or Speech Therapy. Make sure to check all that apply.
6. Indicate the Type of therapy being rendered and provide an Authorization start date if different from the evaluation date.
7. Document the Date of onset/injury and Planned number of sessions (1, 2, or 3+ visits).
8. Specify Body regions being treated and their locations. Use checkboxes for clarity on treatment areas.
9. Complete any additional clinical questions regarding functional deficits and equipment needs based on patient assessment.

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