Get Amerigroup Therapy Request Form

The Amerigroup Therapy Request Form is a crucial document needed to initiate therapy services for members. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently in an online format.

Follow the steps to complete the Amerigroup Therapy Request Form online

1. Press the ‘Get Form’ button to access the therapy request form in your online editor.
2. Fill in the member information section, including the member's name, Medicaid/CHIP ID number, diagnosis codes, and contact details such as phone number and date of birth.
3. Specify the type of therapy requested by selecting the appropriate boxes for physical therapy, occupational therapy, or speech therapy and include the date of onset.
4. Indicate the place of service by checking the corresponding box, whether it's an office, patient home, outpatient hospital, or other specified locations.
5. Provide therapy provider information, including the provider's name, contact name, Amerigroup member ID number, NPI, Texas Provider Identifier, phone, and fax number.
6. Determine if the member is currently receiving the same type of therapy. If yes, provide details of the current provider, diagnosis, frequency, and duration.
7. Complete the ordering physician information section, ensuring to include the physician's name, contact details, NPI, and reason if the ordering physician is out-of-network.
8. Select the therapy service request type as either initial, ongoing services, acute, or developmental delay.
9. Fill out CPT/CMS codes, frequency, number of visits, and requested dates of service for each type of therapy.
10. Address the hearing test question by marking yes or no, and if applicable, include the results and any descriptions of the treatment plan for an abnormal hearing test.
11. For both initial and ongoing services, provide standardized test scores and include required information such as overall goals met, anticipated completion date of the therapy treatment plan, and any barriers faced.
12. Lastly, review all entries for accuracy, save your changes, and follow the necessary instructions to download, print, or share the completed form.

Complete your Amerigroup Therapy Request Form online today to initiate therapy services.