Follow the steps to easily fill out and submit the Therapy Request Form.

1. Click ‘Get Form’ button to access the Therapy Request Form and open it in your preferred online editor.
2. Begin by providing the therapy provider information. Include the facility or provider name, street address, city, state, telephone number, ZIP code, and fax number. Make sure to fill in the provider tax ID number and the appropriate national provider identifiers (NPI) for billing.
3. Next, fill out the patient information section. Enter the first and last name of the patient, their Anthem BC/BS member ID number, date of birth in the specified format, and Medicare member ID number.
4. In the request information section, indicate the request type—whether it's for the onset or extension of therapy services. If applicable, specify if this request pertains to post-operative therapy visits, and include the initial evaluation date and any other relevant procedure details.
5. Select the service type required for the therapy—physical therapy or occupational therapy—along with the corresponding diagnosis code in ICD-10 format.
6. Ensure that all requested information is printed clearly in black ink, with one character per box and all circles filled appropriately.
7. Once completed, fax the request form along with any supporting clinical documentation to OrthoNet at 1-844-340-6419. Ensure that this form serves as page 1 of the fax.
8. Lastly, save changes to your document, download a copy for your records, print the form if needed, or share it as required.

Start filling out the Therapy Request Form online today to ensure timely processing of your prior authorization requests.