Empire orthonet form 2025

1. Click ‘Get Form’ to open the empire orthonet form in the editor.
2. Begin by filling in the 'Fax Date' and '# of Pages Faxed' fields at the top of the form. Ensure you print clearly in black ink, one character per box.
3. In the 'THERAPY PROVIDER INFORMATION' section, provide details such as Facility Name, Provider First and Last Name, Street Address, City, State, Telephone Number, Return Fax Number, Facility/Provider ID Number, National Provider Identifier (NPI), and Tax ID Numbers.
4. Next, move to the 'PATIENT INFORMATION' section. Fill in the patient's First Name, Last Name, Date of Birth, and Alpha Prefix Member ID Number.
5. In the 'REQUEST INFORMATION' section, specify what you are requesting along with the Diagnosis Code in ICD-10 format. Indicate if this request is for post-operative therapy visits by selecting 'Yes' or 'No'.
6. Finally, select the Service Type (Physical Therapy or Occupational Therapy) and provide the Initial Evaluation Date.

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