Get Universal Pt/ot/speech Prior Authorization Form - Absolute Total ...

This guide provides you with a clear and user-friendly approach to completing the Universal PT/OT/Speech Prior Authorization Form – Absolute Total for BabyNet therapy services. By following these steps, you’ll be able to fill out the form accurately and efficiently online.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the Universal PT/OT/Speech Prior Authorization Form and open it for editing.
2. Begin filling out the patient’s name in the designated fields, ensuring that you include the first name, middle name, last name, and date of birth.
3. Input the patient’s full address including street, apartment number, city, state, and zip code, followed by their phone number.
4. Enter the Medicaid number associated with the patient.
5. Complete the parent or guardian’s name along with their relationship to the patient. Ensure to provide their first name, middle name, and last name.
6. Select the type of therapy required by marking 'Physical', 'Occupational', or 'Speech'.
7. Enter the initial diagnosis along with the corresponding ICD9 code.
8. Input the CPT code, therapy initiation date, and mention the frequency of therapy sessions.
9. Specify the place of service and indicate how many times therapy will take place weekly or monthly.
10. Attach any required supporting documentation by marking the corresponding boxes, which include physician’s orders, therapist evaluations, and treatment documentation.
11. Fill in the therapist’s name, phone number, and NPI number, if applicable.
12. Complete the fields related to the plan point of contact and request date, ensuring all information is accurate.
13. Review all entered information for accuracy before submitting.
14. You can now save your changes, download, print, or share the completed form as needed.

Complete your documentation online today and ensure a smooth prior authorization process.