Get 617 972 9409

This guide provides a clear and comprehensive approach to filling out the 617 972 9409 Occupational Therapy Authorization Form online. By following the steps outlined below, users can efficiently complete and submit the form to ensure ongoing coverage.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's name in the designated field. This identifies the individual requesting occupational therapy authorization.
3. Input the date of birth (DOB) in the appropriate section to confirm the member’s age.
4. Fill in the date of injury (DOI) to document when the member experienced the relevant issue.
5. Provide the date of the report. This should reflect the current date the form is being filled out.
6. Enter the diagnosis (Dx) which describes the medical condition being addressed.
7. Input the member ID number to uniquely identify the individual's healthcare record.
8. Fill in the facility name which is responsible for providing the therapy services.
9. Provide the facility phone number and fax number for communication purposes.
10. After completing the necessary fields, review the previous prescription section, marking yes or no as applicable.
11. Indicate the total number of visits since the start of care and specify the number of visits requested.
12. Estimate the expected discharge (D/C) date and provide current clinical and functional status details.
13. Report on pain intensity and include details for range of motion, strength, alignment, balance, and reflexes as guided by the fields.
14. Document the current treatment plan, clinical goals, and functional outcomes in the corresponding sections.
15. Lastly, ensure the provider's name, number, requested by section, and signature are completed for verification.
16. Once all fields are filled out accurately, save the changes and choose the option to download, print, or share the filled form as required.

Complete your documents online efficiently today.