Get ActivHealthCare Chiropractic Treatment Plan Form

P. O. Box 1368 Lilburn GA 30048 ph 770. 455. 0040 toll free 888. 635. 0459 fax 678. 990. 0025 CHIROPRACTIC TREATMENT PLAN FORM Please Print or Type Clearly Note If all information is not filled out completely and accurately this form will be returned without authorization. Date Network Doctor s Name Treating Doctor Patient Information Last First Middle Member ID DOB Suffix Height Provider Information Provider Name Phone Federal Tax ID Fax NPI Prior Diagnoses List primary diagnoses for which you have treated this patient in the last 12 months. Diagnoses Past 12 Months ICD9 Code Current Diagnoses From Start Date Date Current Condition Began of Treatments To End Date Patient Type check one New to your office Established Patient New Injury First Visit for Current Condition Start date for THIS authorization Number of additional visits requested over days or weeks. 1. Etiology or cause of current condition 2. What is the patient primary complaint 3. Have you completed the acute phase of treatment Has the patient been compliant 4. Initial Pain Level Circle one 5. Current Pain Level Circle one 6. Percentage of recovery to date 7. Is there anything about this case that makes it unusual or that may hinder your progress Signature Print Name Title if other than provider. Diagnoses Past 12 Months ICD9 Code Current Diagnoses From Start Date Date Current Condition Began of Treatments To End Date Patient Type check one New to your office Established Patient New Injury First Visit for Current Condition Start date for THIS authorization Number of additional visits requested over days or weeks. 1. Etiology or cause of current condition 2. What is the patient primary complaint 3. Have you completed the acute phase of treatment Has the patient been compliant 4. 1. Etiology or cause of current condition 2. What is the patient primary complaint 3. Have you completed the acute phase of treatment Has the patient been compliant 4. Initial Pain Level Circle one 5. Current Pain Level Circle one 6. Percentage of recovery to date 7. Initial Pain Level Circle one 5. Current Pain Level Circle one 6. Percentage of recovery to date 7. Is there anything about this case that makes it unusual or that may hinder your progress Signature Print Name Title if other than provider. Diagnoses Past 12 Months ICD9 Code Current Diagnoses From Start Date Date Current Condition Began of Treatments To End Date Patient Type check one New to your office Established Patient New Injury First Visit for Current Condition Start date for THIS authorization Number of additional visits requested over days or weeks. 1. Etiology or cause of current condition 2. What is the patient primary complaint 3. Have you completed the acute phase of treatment Has the patient been compliant 4. Initial Pain Level Circle one 5. Current Pain Level Circle one 6. Percentage of recovery to date 7. 1. Etiology or cause of current condition 2. What is the patient primary complaint 3. Have you completed the acute phase of treatment Has the patient been compliant 4. Initial Pain Level Circle one 5. Current Pain Level Circle one 6. Percentage of recovery to date 7. Is there anything about this case that makes it unusual or that may hinder your progress Signature Print Name Title if other than provider. .