Get Upgrade Request Form - Therapy Network

Filling out the Upgrade Request Form is a straightforward process that ensures your request for an upgrade is properly submitted. This guide offers step-by-step instructions to help streamline your experience and ensure all necessary information is included.

Follow the steps to successfully complete your upgrade request.

1. Click the ‘Get Form’ button to obtain the form and open it in the editing interface.
2. In the 'Facility Requesting Upgrade' section, provide the name of the facility that is requesting the upgrade. This information is crucial for processing the request.
3. Fill in the 'Contact Person' field with the name of the key contact at the facility who can provide further information if needed.
4. Enter the contact phone number and fax number for the facility. Ensuring accurate contact information can facilitate communication.
5. Indicate the type of therapy being requested, selecting from options such as ST (speech therapy), OT (occupational therapy), or PT (physical therapy).
6. Complete the patient's details by entering their name, date of birth, and member ID number. Accurate patient information is vital for correct processing.
7. Specify the current level of therapy and the level being requested. Clearly stating these levels helps in understanding the upgrade needs.
8. Document the current diagnosis of the patient, ensuring it aligns with the request for an upgrade.
9. Include the current referral number and the date of the last visit. This information provides context for the request.
10. Indicate how many visits have been completed along with their dates, as this data supports the need for an upgrade.
11. Review the 'FOR OFFICE USE ONLY' section if applicable, but this is typically filled out by the receiving office.
12. Once all fields are completed, save your changes, and choose to download, print, or share the form as necessary.

Start filling out the Upgrade Request Form online today to expedite your upgrade process.