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Get StateFarm ATPT Form 2004

THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE OF PROVIDER DATE ATPT Form Version 1. ATTENDING PROVIDER TREATMENT PLAN INITIAL SUBMISSION FOLLOW-UP SUBMISSION TYPE OR PRINT LEGIBLY CLAIM PATIENT INFORMATION 1. PATIENT S NAME Last 12. DATE OF ACCIDENT DATE SUBMITTED 13. IS PATIENT S CONDITION RELATED TO 2. PATIENT S ADDRESS No* Street 3. CITY 4. STATE A. EMPLOYMENT 6. TELEPHONE Include Area Code 8. SEX M 9. S*S* NUMBER 20. ZIP CODE NO C. OTHER ACCIDENT Y ES 18. STATE B. AUTO ACCIDENT F 10. INSURANCE COMPANY Initial 17. CITY 7. PATIENT BIRTHDATE Year 16. POLICYHOLDER S ADDRESS No* Street Day POLICYHOLDER INFORMATION if different First Month 21. RELATIONSHIP TO PATIENT 14. IS PATIENT UNABLE TO WORK 11. POLICY NUMBER PROVIDER INFORMATION 22. NAME OF TREATING PROVIDER 23. TAX I. D. NUMBER 26. FACILITY/OFFICE ADDRESS No* Street 24. SPECIALTY 25. FACILITY OR OFFICE NAME 31. EMAIL ADDRESS 32. FAX Include Area Code 34. DATE OF LAST VISIT 33. INITIAL DATE OF TX 35. PATIENT MEDICAL HISTORY. HAS PATIENT EVER HAD ANY OF THE FOLLOWING SERVICES CHECKMARK THOSE APPLICABLE BELOW* NOTE-ALL BOXES CHECKED REQUIRE A BRIEF DESCRIPTION OF SERVICE AND DATE PROVIDED ON SEPARATE ATTACHMENT MRI ALL MEDICATION 36. PRIMARY DIAGNOSIS ICD-9 SURGERY 37. SECONDARY DIAGNOSIS ICD-9 X-RAY DIAGNOSTICS TESTING 38. ADDITIONAL DIAGNOSIS ICD-9 OTHER PROPOSED COURSE OF TREATMENT AS IT RELATES TO THIS MVA 40. DATE S OF TREATMENT REQUESTED 41. CHECK APPROPRIATE CARE PATH If applicable FROM TO CP1 CP2 CP4 CP3 CP6 CP5 42. REQUEST FOR SERVICES CPT / HCPS / NDC CODES FREQUENCY Times per visit Use left box for single codes or left and right box for a range of codes Visits per week DURATION Number of weeks TOTAL UNITS 42. CHECKMARK ATTACHMENTS BELOW* NOTE-ALL SUPPORTING DOCUMENTS CHECKED MUST BE PROVIDED ON SEPARATE ATTACHMENT SOAP NOTES PROGRESS NOTES TEST RESULTS MEDICAL HISTORY PRESCRIPTIONS FRAUD PREVENTION-NEW JERSEY WARNING ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES* PROVIDER STATEMENT I HAVE PERSONALLY COMPLETED AND REVIEWED THIS FORM. ATTENDING PROVIDER TREATMENT PLAN INITIAL SUBMISSION FOLLOW-UP SUBMISSION TYPE OR PRINT LEGIBLY CLAIM PATIENT INFORMATION 1. PATIENT S NAME Last 12. DATE OF ACCIDENT DATE SUBMITTED 13. IS PATIENT S CONDITION RELATED TO 2. PATIENT S ADDRESS No* Street 3. PATIENT S NAME Last 12. DATE OF ACCIDENT DATE SUBMITTED 13. IS PATIENT S CONDITION RELATED TO 2. PATIENT S ADDRESS No* Street 3. CITY 4. STATE A. EMPLOYMENT 6. TELEPHONE Include Area Code 8. SEX M 9. S*S* NUMBER 20. ZIP CODE NO C. CITY 4. STATE A. EMPLOYMENT 6. TELEPHONE Include Area Code 8. SEX M 9. S*S* NUMBER 20. ZIP CODE NO C. OTHER ACCIDENT Y ES 18. STATE B. AUTO ACCIDENT F 10. INSURANCE COMPANY Initial 17. CITY 7. PATIENT BIRTHDATE Year 16. OTHER ACCIDENT Y ES 18. STATE B. AUTO ACCIDENT F 10. INSURANCE COMPANY Initial 17. CITY 7. PATIENT BIRTHDATE Year 16. POLICYHOLDER S ADDRESS No* Street Day POLICYHOLDER INFORMATION if different First Month 21. RELATIONSHIP TO PATIENT 14. .

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