Get TX CSHCN TP1 2007

Request for Initial Outpatient Therapy Form TP-1 CCP - Texas Medicaid Healthcare Partnership PO Box 200735 Austin TX 78720-0735 1-800-846-7470 CCP FAX 1-512-514-4212 Medicaid Number Client Name Date of birth / Telephone Client Address Has the child received therapy in the last year from the public school system Date of Initial Evaluation PT OT Yes No ST A copy of the initial evaluation must be attached Date of onset Diagnoses Use ICD-9 diagnosis codes for prior authorization requests received by TMHP on or before September 30 2014. Use ICD-10 diagnosis codes for prior authorization requests received by TMHP on or after October 1 2014 Category of Therapy Being Requested Pre-surgery Post-surgery Date of surgery / / Cast Removal Date Removed / / Serial Casting Acute Episode of Chronic Condition New Condition Specialty Clinic Home Program ADL activities of daily living Equipment Assessment Equipment Training Speech for Craniofacial Developmental Anomalies New Condition Post Cochlear Implant PT/OT for Check the service requested indicate the date s of service and frequency per week Dates of service cannot exceed six months. If possible end requested date of service on the last day of the month. Service Date s Service Type and Modifier Frequency per week From PT GP OT GO ST GN To Procedure code s for therapy services Physician signature is required unless one of the following from the physician is attached to request a signed and dated prescription a dated written order or a dated documented verbal order. A CNM CNS NP or PA may sign all documentation related to the provision of therapy services on behalf of the client s physician when the physician delegates this authority. Specialist Name Signature Date Signed Physician PT Therapist Provider Information Fax Address TPI NPI Taxonomy Benefit Code Effective Date03172014/Revised Date02052014. Use ICD-10 diagnosis codes for prior authorization requests received by TMHP on or after October 1 2014 Category of Therapy Being Requested Pre-surgery Post-surgery Date of surgery / / Cast Removal Date Removed / / Serial Casting Acute Episode of Chronic Condition New Condition Specialty Clinic Home Program ADL activities of daily living Equipment Assessment Equipment Training Speech for Craniofacial Developmental Anomalies New Condition Post Cochlear Implant PT/OT for Check the service requested indicate the date s of service and frequency per week Dates of service cannot exceed six months. If possible end requested date of service on the last day of the month. Service Date s Service Type and Modifier Frequency per week From PT GP OT GO ST GN To Procedure code s for therapy services Physician signature is required unless one of the following from the physician is attached to request a signed and dated prescription a dated written order or a dated documented verbal order. If possible end requested date of service on the last day of the month. Service Date s Service Type and Modifier Frequency per week From PT GP OT GO ST GN To Procedure code s for therapy services Physician signature is required unless one of the following from the physician is attached to request a signed and dated prescription a dated written order or a dated documented verbal order. A CNM CNS NP or PA may sign all documentation related to the provision of therapy services on behalf of the client s physician when the physician delegates this authority. .