Get Rehabilitative Services Request Form 2464 - Dads State Tx

Filling out the Rehabilitative Services Request Form 2464 is a crucial step in accessing necessary therapy services. This guide will provide you with clear and efficient instructions to help you complete the form online, ensuring that all necessary information is submitted accurately.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate whether the recipient has a diagnosis of intellectual disability, cerebral palsy, developmental delay, or a closed head injury before the age of 22 years by choosing 'Yes' or 'No'. If 'Yes', complete Form 2465.
3. Select the type of therapy request: Physical Therapy (PT), Speech Therapy (ST), or Occupational Therapy (OT). Also, specify whether this is a new request, a recertification, or a restarted service.
4. Fill in personal information including the recipient's name, Social Security number, date of birth, primary medical diagnosis, Medicaid number, and the date of the primary medical diagnosis.
5. Provide details on other medical diagnoses along with their dates diagnosed, along with the nursing facility's name and location if applicable.
6. Enter hospitalization dates, area code, and telephone number. Also, fill in the Medicaid provider number and vendor number as necessary.
7. Document the current functional status in measurable terms, listing at least four aspects without crowding the information.
8. Outline thirty-day goals in measurable terms, again ensuring clarity and no overcrowding of information.
9. Indicate the recipient's orientation and ability to participate. Ensure to check the appropriate therapy services required.
10. Final review is important. After ensuring all fields are completed accurately, save any changes, download the form, print it, or share it as needed.

Ensure your therapy request is submitted correctly by completing the Rehabilitative Services Request Form 2464 online today.