Follow the steps to complete the Orthonet Humana form.

1. Click the ‘Get Form’ button to access the document and open it for editing.
2. Enter the date of the fax and the total number of pages being sent, ensuring this form is at the top of your fax.
3. Provide therapy provider information, including facility name, address, city, state, telephone number, ZIP code, fax number, National Provider Identifier (NPI), and both provider and facility tax ID numbers.
4. Fill out the patient information section, including the patient's first and last name, Humana member ID number, and diagnosis code in ICD-10 format.
5. In the request information section, select whether the request is for onset of therapy services, extension of therapy services, or another procedure. Indicate the service type (physical therapy, occupational therapy, or speech therapy).
6. Enter the patient's date of birth, ensuring to format it accurately. Indicate whether this request is for post-operative therapy visits and whether an Advanced Coverage Determination (ACD) is needed for Humana Medicare Advantage PFFS members.
7. Provide the initial evaluation date using the proper format.
8. Make sure to print all information clearly in black ink, filling in each circle completely where applicable.
9. Save any changes and consider sending or sharing the completed form, ensuring all necessary clinical documentation is attached.

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