Get Pt/ot Treatment Request Clinical Worksheet

The PT/OT Treatment Request Clinical Worksheet is an essential document for healthcare providers to request treatment for patients experiencing pelvic pain or incontinence. This guide will assist you in navigating the online form efficiently, ensuring all necessary information is accurately provided.

Follow the steps to complete the treatment request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of submission in the designated section.
3. Fill out the rendering provider information completely, including the therapist's last and first names, group or facility name, billing provider TIN, and complete address. Make sure to include the provider's phone and fax numbers.
4. Enter the patient information, including their last and first names, date of birth, member ID, and mailing address. Also, complete the subscriber's last and first names and payor name along with a contact phone number.
5. In the clinical information section, provide the primary ICD/diagnosis code and description, along with the start date of the request.
6. Indicate whether additional care is required for the same condition treated in the last 60 days or if treatment is required for a new condition. If a new condition is present, specify the previous condition.
7. Complete fields related to the previous treatment status and additional details as required, including dates of onset and evaluations.
8. For pelvic pain, if it is the primary diagnosis, answer questions on pelvic or S.I. joint asymmetry, and related tests performed. Note the pain level and number of incontinence/leakage events per day.
9. For incontinence, if it is the primary diagnosis, indicate the presence of urinary and bowel symptoms, structural problems, and the number of incontinence events.
10. Fill in any additional information required and complete the Patient Specific Functional Scale for activities the patient has difficulty performing.
11. After filling out the entire form, save your changes. You will have the option to download, print, or share the completed form as needed.

Complete your PT/OT Treatment Request Clinical Worksheet online today.