Get Physician Authorization For Restortive Service Form

Filling out the Physician Authorization For Restorative Service Form online can seem daunting, but with this guide, you will find it straightforward and manageable. This form is crucial for documenting a patient's need for restorative services, ensuring proper evaluation and treatment.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Input the patient's last name, first name, middle name, and social security number in the designated fields.
3. Fill in the referring physician's name, the patient's date of birth, and their employer’s details.
4. Provide the date of the injury and the patient's height and weight.
5. Complete the employer's address, phone number, and fax number in the appropriate sections.
6. Specify the insurance carrier and the provider's details, including their address and discipline (MD, DO, DC, PT, OT).
7. Enter the provider's tax ID number, adjuster's name, phone, and fax numbers.
8. Detail any other conditions or complicating factors that may affect recovery.
9. Describe the diagnosis specific to the industrial claim.
10. List the patient's essential job functions and measurable requirements needed to return to work without restrictions.
11. Record capabilities for multiple visits, specifying maximum weights and frequencies as instructed.
12. Document the patient's reported average pain intensity on a scale from 0 to 10 and their average pain frequency throughout the day.
13. Outline the treatment plan, indicating frequency and types of therapies involved.
14. Estimate the expected number of visits required to reach the stated functional goals.
15. Provide comments from the provider, sign and date the form, and include the payor’s approval if applicable.
16. After completing all sections, save your changes, then choose to download, print, or share the form as needed.

Complete your Physician Authorization For Restorative Service Form online today to ensure timely processing.