Fillable Letter of Medical Necessity for Therapy Plagiocephaly (skull)

Fill Online, Printable, Fillable, Blank Letter of Medical Necessity for Therapy Plagiocephaly (skull) Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Letter of Medical Necessity for Therapy Plagiocephaly (skull)

On average this form takes 11 minutes to complete

The Letter of Medical Necessity for Therapy Plagiocephaly (skull) form is 1 page long and contains:

  • 0 signatures
  • 45 check-boxes
  • 22 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Letter of Medical Necessity for Therapy
Client’s Name: ______________________________________________________ DOB: ___________________
Medical Diagnosis: ___________________________________________________ ICD 9 code: ______________
Please check all of the diagnoses below that apply:
Abnormality of Gait 781.2
Delayed Milestones 783.42
Mechanical Problems with Limbs V49.1
Hypotonia 728.9
Apraxia 784.69
Motor Problems with Limbs V49.2
Muscle Weakness 728.87
Feeding: Eating Disorder 307.59
Sensory Problems with Limbs V49.3
Lack of Coordination 781.3
Feeding Difficulties: Infant 783.3
Sensory Problems with Neck/ Trunk V48.5
Torticollis (congenital) 754.1
Plagiocephaly (skull) 754.0
Dysphagia: Oral 787.21
Dysphagia: Pharyngeal 787.23
Mechanical & Motor Problems w/ Neck/
Trunk V48.3
Difficulty In Walking 719.97
Fluency Disorder 315.35
Expressive Language Disorder 315.31
______________________
_________________________
Articulation/ Phonological
Disorder 315.39
Mixed Receptive/Expressive Language
Disorder 315.32
Service Frequency Duration Therapist’s Signature
Physical Therapy
____ x/_____
____ mo
Occupational Therapy
____ x/_____
____ mo
Speech Therapy
____ x/_____
____ mo
Suggested Interventions:
Neuromuscular Re-Education (97112) Treatment of Speech / Language (92507)
Therapeutic Procedure (97110) Feeding / Swallowing / Oral-Motor (92526)
Therapeutic Activities (97530) Orthotics Management / Training (97760, 99762)
Gait Training (97116) ADLs / Self-Care including AAC device training (97535)
Manual Therapy Techniques (97140) Assistive Technology & Adaptive Equipment (97535)
Massage (97124) Group: OT, PT (97150) Speech (92508)
Evaluation/ Re-Evaluation Other: _________________________________________
An early intervention specialist (EIS) is providing specialized skills training (SST) &/or case management with
this client on a regular basis. A therapist (licensed professional of the healing arts- LPHA) will monitor services
for effectiveness in reducing functional limitations and achieving proper growth and development every six
months at a minimum. This monitoring may include evaluating/ re-evaluating the child and modifying the IFSP.
Therapy services provided by a licensed therapist are medically necessary for this client:
___________________________________________________________ ________________________
Physician Sign Here Date
Physician’s Name (Print):_______________________________________________________________________
Address:_____________________________________________________________________________________
Phone #:_________________ Fax #:_________________ Project TYKE phone: 281-237-6647 fax: 281-644-1846
This “Letter of Medical Necessity” is the last page of the therapy evaluation/ re-evaluation: No Yes: page ___
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Letter of Medical Necessity for Therapy Plagiocephaly (skull)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document