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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Requesting Provider Information' section. Enter today’s date, your practice name, address, phone number, referring physician's name, fax number, NPI number, and your name.
Next, move to the 'Patient Information' section. Input the patient's name, date of birth (DOB), address, city/state/zip code, preferred phone number, cell number, insurance company details including ID/subscriber number and telephone number.
Indicate the type of therapy required by checking the appropriate boxes for options like 'Evaluate and Treat', 'Hand Therapy', or any specific custom splint needed.
Specify frequency of therapy sessions per week and weight-bearing status. Fill in any additional instructions or precautions as necessary.
Finally, ensure you sign and date the form at the bottom to certify that the services are medically necessary.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (53 Votes)
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2021	4.8 Satisfied (58 Votes)
2021	4.7 Satisfied (140 Votes)
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2020	4.3 Satisfied (177 Votes)
2020	4.8 Satisfied (71 Votes)
2019	4.9 Satisfied (31 Votes)
2019	4.8 Satisfied (110 Votes)
2019	4.5 Satisfied (54 Votes)
2019	4.7 Satisfied (55 Votes)
2019	4.1 Satisfied (55 Votes)

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