Download REQUEST FOR TREATMENT PLANNING

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: