Follow the steps to complete the intake form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Date of Submission' field. This should reflect the current date when the form is being completed.
3. If applicable, enter the 'Previous Reference/Auth Number' which is used for continued care. If this is your first request, you may leave it blank.
4. Select the 'Service Type Requested' by choosing either Physical Therapy or Occupational Therapy.
5. Fill in the 'Patient' section with the first name, middle initial, last name, date of birth, and gender of the individual receiving treatment. Be sure to provide the complete street address along with any apartment number, city, state, and zip code.
6. In the contact information section, include home and cell phone numbers, selecting the primary contact method.
7. Identify the 'Member Health Plan/Insurer' to ensure proper authorization.
8. In the 'Provider' section, enter the first and last name, primary specialty, tax identification number (TIN), and other relevant details about the healthcare provider managing the treatment.
9. For the 'Administrative' segment, document any diagnoses with codes and descriptions, including important dates related to the request.
10. In the 'Clinical' section, specify the cause or problem related to lymphedema and indicate the primary treatment areas affected.
11. Fill in the lymphedema stage by selecting the appropriate classification based on the patient’s condition.
12. Indicate whether volume measurements are available, and if so, record relevant figures, specifying affected sides and treatment phases.
13. For follow-up requests, indicate if the patient has received a compression garment and how they are responding to treatment.
14. For post-mastectomy patients, please specify the number of visits requested per week and total weeks of care required.
15. Review all filled fields for accuracy and completeness. Users can then either save changes, download, print, or share the form as needed.

Complete your EviCore Healthcare Lymphedema Program intake form online today for efficient processing!