Get Physical Therapy Pre-certification Form Initial ... - Qualcare Inc.

Completing the Physical Therapy Pre-Certification Form Initial for QualCare Inc. is an essential step in obtaining prior authorization for therapy services. This guide will walk you through the steps to accurately fill out the form online, ensuring all necessary information is provided for a smooth submission process.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in your chosen editor.
2. Enter the patient's name, ID number, group, date of birth, and age in the designated fields.
3. Indicate if the patient has other medical insurance by selecting 'Yes' or 'No.' If 'Yes,' provide the insurance name and policy number.
4. If the request is due to a motor vehicle accident or other incident, fill in the date of the accident and the insurance name and phone number.
5. Input the date of the initial evaluation and the number of requested visits for the therapy.
6. Detail the primary symptoms experienced by the patient, including their duration and frequency (constant or intermittent).
7. Assess and record the quality of pain, selecting options such as ache, burning, numbness, etc., and rate the pain level on a scale from 0-10 for current, best, and worst experiences.
8. Document when the symptoms were exacerbated and the onset date, as well as whether the injury was due to a motor vehicle accident, workers' compensation, or other causes.
9. Fill in the range of motion (ROM) measurements for both active and passive movements across specified upper extremity functions, including shoulder and elbow assessments.
10. Evaluate and note any functional limits, detailing if there are difficulties with activities of daily living or fine motor skills.
11. Provide additional information or special testing results, as necessary, and list the diagnosis using the ICD 9 code.
12. List short-term and long-term goals for therapy in the designated sections.
13. Complete the provider information, including the tax ID number, phone number, and contact name/fax number.
14. Review all entries for accuracy and completeness before saving changes, downloading, printing, or sharing the completed form.

Take the next step in your patient's care by completing the Physical Therapy Pre-Certification Form online.