Get Evicore Healthcare Lymphedema Program: Pt/ot Therapy Intake Form 2020-2026

Filling out the EviCore Healthcare Lymphedema Program PT/OT Therapy Intake Form online is a straightforward process. This guide will provide you with step-by-step instructions to ensure that all necessary information is submitted accurately and completely.

Follow the steps to successfully complete the intake form.

1. Click ‘Get Form’ button to access the form and open it in the designated viewing tool.
2. Begin by entering the date of submission at the top of the form. This ensures that the request is processed in a timely manner.
3. If applicable, input the previous reference or authorization number for continued care. This field is important for tracking ongoing treatment.
4. Select the service type requested by indicating either physical therapy or occupational therapy. This step is essential for directing your request appropriately.
5. Provide the patient's personal information. Fill out the first name, middle initial, last name, date of birth (in mm/dd/yyyy format), and gender. Ensure the accuracy of this data for identification purposes.
6. Complete the patient's contact details including street address, apartment number, city, state, zip code, home phone, and cell phone. Indicating which number is primary (home or cell) is also required.
7. Enter the member's health plan or insurer information. This helps to verify insurance coverage for the requested services.
8. Fill out the provider’s information, including their first and last name, primary specialty, TIN, phone, fax, address, suite number, city, and state to ensure the request reaches the right healthcare professional.
9. Input the administrative details such as NPI, descriptions and codes associated with the services being requested.
10. Specify the start date for the request and select the appropriate response from the options provided: whether it is a new condition or a same/previous condition, and input relevant dates.
11. Indicate the cause or problem of the lymphedema. Select from the options provided to accurately describe the condition being treated.
12. Identify the primary treatment area(s) by selecting the appropriate options, including limbs, trunk, or other specified areas.
13. Specify the lymphedema stage by selecting the stage that best describes the patient's condition. This is critical for treatment planning.
14. Indicate whether volume measurements are available. If yes, provide the necessary measurements and specify the affected side.
15. Outline the treatment phase by selecting either phase 1 (reductive) or phase 2 (maintenance), and state if a compression garment has been received.
16. For follow-up requests, confirm if the patient is responding to treatment and answer any additional relevant queries regarding post-mastectomy details.
17. Finally, review all entries for accuracy before saving or submitting the form. You may also download, print, or share the completed document as needed.

Complete your intake form online today to expedite your request for therapy services.