Number of previous therapy visits used: PT _______ OT _______ ST _______
Date range for authorization request: _____________________ through _____________________
PT visits requested: _____________ Frequency: _________________________________________
OT visits requested: _____________ Frequency: _________________________________________
ST visits requested: _____________ Frequency: _________________________________________
Primary diagnosis code: __________________ Diagnosis description: _______________________________
Secondary diagnosis code(s): ______________ Diagnosis description: _______________________________
When submitting an initial request, please include documentation for ALL
of the following elements. Check items included with this request.
☐ Standardized objective assessments of the patient's impairments, functional limitations,
and disabilities
☐ Therapy diagnosis and prognosis
☐ Patient-specific objectively measurable goals of treatment and expected outcomes for:
• Activity/Performance
• Specific functional outcomes
• Objective measurements of the activity/performance
• Time frame for achieving goals
☐ A patient-specific plan of treatment
☐ A patient-specific discharge plan
☐ An established home exercise program
When submitting a request for ongoing therapy, please include documentation for ALL
of the following:
☐ A copy of the Initial Evaluation for current plan of care
☐ A summary assessment of the patient's impairments, functional limitations, and disabilities including:
• The reduction in intensity and frequency of symptoms
• Improvements in function and reductions in limitations
• Prognosis for further clinical or functional improvement
☐ A summary of progression towards the goals of treatment plan and independence in
self-management
☐ Provider documentation of compliance by member/caregiver regarding their home exercise program and
continued teaching of the home exercise program
