Follow the steps to complete the intake form online.

1. Click ‘Get Form’ button to access the form and open it in your online editing tool.
2. Begin by entering the patient's first name, middle initial, and last name in the designated fields.
3. Fill in the patient's date of birth using the mm/dd/yyyy format and select their gender from the available options.
4. Provide the patient's member ID and contact information, including their address, home phone, and cell phone.
5. Next, select the service type requested (Physical Therapy or Occupational Therapy) and enter the date of submission.
6. Complete the provider's information, including their first name, last name, specialty, TIN, NPI, and contact details.
7. In the administrative section, list any diagnoses along with corresponding codes and descriptions as outlined in the form.
8. Indicate the start date for this request and specify whether it is a new condition or a continuation of care by selecting the appropriate response.
9. Describe the primary treatment area(s) that require attention and include any relevant details such as lymphedema stage and corresponding measurements.
10. Select the treatment phase and indicate whether the patient has received a compression garment if applicable.
11. For post-mastectomy patients, enter the number of visits requested per week and the number of weeks of care needed.
12. Review all entered information for accuracy before saving changes, downloading, printing, or sharing the form.

Complete your EviCore Healthcare Lymphedema Program intake form online today to ensure timely processing of your request.