Get Chiropractic Request Form - Orthonet

Filling out the Chiropractic Request Form - OrthoNet is a straightforward process designed to facilitate the submission of treatment requests. This guide provides clear, step-by-step instructions to ensure that users can efficiently complete the form online.

Follow the steps to fill out the Chiropractic Request Form - OrthoNet online.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin with the section for chiropractic provider information. Fill in the street address, city, state, and telephone number. Also, provide the return fax number and the provider tax ID number.
3. Proceed to the patient information section. Input the patient's first name, last name, date of birth (month, day, year), ZIP code, and the BCBSIL member ID number.
4. Indicate the total number of chiropractic visits to date this calendar year, the exam date for the current request, and the requested start date.
5. Fill out the primary diagnosis code by selecting the chief complaint. You may also choose onset details that apply to the patient's condition.
6. Continue with the diagnosis codes 2, 3, and 4 by providing relevant information based on the patient's symptoms, such as low back pain, headaches, or any other condition listed.
7. Indicate the average pain intensity on a scale from 0 to 10 and specify any range of motion or functional limitations the patient may have.
8. Complete the sections on muscle strength limitations, nerve abnormalities, and outcomes assessment scores by selecting the appropriate options and inputting any necessary details.
9. Verify the information entered for accuracy. Once satisfied, save changes to the document for future reference.
10. You may download, print, or share the completed form as required after saving your final inputs.

Complete your documents online to streamline your chiropractic treatment requests.