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This guide provides clear instructions on completing the Precertification Form for various physical medicine services online. By following these steps, users can ensure that all necessary information is accurately submitted for precertification.

Follow the steps to complete the form accurately and efficiently.

1. To begin, press the ‘Get Form’ button to acquire the Precertification Form. This action will open the form in your preferred editor.
2. Fill in the required information at the top of the form, including the date, patient name, date of injury (DOI), claim number, and insurance details.
3. Enter the diagnosis along with the corresponding ICD-9 code provided by the attending physician.
4. Complete the section for the attending physician by indicating their name and the evaluation date.
5. Record the number of treatments your office has provided to date, the number of treatments from the last certification, and any missed appointments during the last certification period.
6. Specify the treatment dates for this precertification by indicating the start and end dates.
7. Provide subjective reports detailing the patient's symptoms and experiences, ensuring to include relevant information clearly.
8. Rate the pain scale on a scale from 1 to 10, or indicate 'NA' if not applicable.
9. Outline any current functional limitations the patient is experiencing.
10. Describe the progress made during the last certification period.
11. Set measurable and functional goals for this certification period to guide treatment.
12. Propose a treatment plan, including how frequently treatments will occur each week.
13. Include the CPT code relevant to the treatment plan and the expected number of weeks for treatment.
14. Add any necessary comments or justifications for further treatment.
15. The treating therapist/provider must sign the form, print their name and credentials, and fill out facility information, including phone, fax, and tax ID.
16. Once completed, review all sections of the form for accuracy, then save changes, download, print, or share the document as needed.

Complete and submit your precertification form online today!