Get Physmetrics - Chiro Pretreatment Request Form Rev. 2019.doc

Filling out the Physmetrics - CHIRO Pretreatment Request Form Rev. 2019.doc is an important step in ensuring proper treatment preparation. This guide provides a detailed, step-by-step approach to completing the form accurately and efficiently online.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the Physmetrics - CHIRO Pretreatment Request Form Rev. 2019.doc and open it in the appropriate online tool.
2. Begin by selecting the type of review you are submitting: Concurrent Review, Minor, Massage.
3. Enter the patient’s name and date of birth in the specified fields. Ensure to accurately provide the age and sex of the patient.
4. Fill in the insurance ID number along with the patient’s occupation and insurance plan/employer details.
5. Clearly print the treating provider's name in the designated field.
6. Indicate if the treatment is for an accident or injury by ticking 'Yes' or 'No' and providing the date and type of accident if applicable.
7. Document any prior chiropractic treatment within the last 12 months, including the date of onset and response to care.
8. Record the total number of visits in the past year, as well as details of the first and most recent visit.
9. Note the date of discharge from any prior treatment and provide the reason if known.
10. List the diagnoses in the specified ICD codes sections. Up to four codes can be provided.
11. Outline the history of the patient’s condition and their subjective complaints in the provided areas.
12. Summarize the objective findings observed during the examination.
13. Specify any functional outcome measures used, such as the Oswestry or back and neck index.
14. Detail the treatment plan as discussed and any procedure requests along with corresponding CPT codes.
15. If applicable, fill in information regarding massage/manual therapy, indicating who will perform the treatment.
16. Select if retro-approval is needed and explain the reason if so.
17. Include the request submitted date and the effective date requested, ensuring it is within 30 days.
18. Finally, sign and date the form at the bottom, and provide a fax number to ensure transmission.

Take the next step to efficiently complete your documentation online.