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REQUEST FOR TREATMENT PLANNING Patient Information Patient Name: DOI: Height: Date of Birth: Mechanism of Injury: Employer: Job title: Working? Y N Restrictions? Y N If yes, please list: List previous workplace injuries: Date(s): Legal Representative: Phone: Other Medical conditions: Diabetes Depression Arthritis (where?) List ALL current medications: Weight: Treating Doctor Information Treating Doctor: License #: Complete Address: Specialty Tax ID#: Phone number and times available for a peer to peer conversation: Fax#: History History: Please give a brief history of present illness related to injury and important clinical findings including relevant diagnoses and codes. Description: ICD9 Codes: Treatment Plan Treatment Plan must include CPT codes, frequencies, timeframes, and medications (not to exceed one month for sub-acute and early chronic cases less than one year from date of injury). CPT Description Codes Surgery: Injections: Freq.: Rehab: Medications: DME: Rationale and or evidence basis for proposed services (Must be specific): REQUSTING PHYSICIAN SIGNATURE: PHYSICIAN ADVISOR SIGNATURE: Approved Denied Comments: DATE: DATE: