Get Evicore Healthcare Pt/ot Therapy Intake Form: Neurological Conditions 2019-2025

Filling out the EviCore Healthcare PT/OT Therapy Intake Form for neurological conditions is an essential step in receiving appropriate therapy services. This guide provides clear instructions to help users complete the form easily and efficiently.

Follow the steps to complete the therapy intake form.

1. Click ‘Get Form’ button to obtain the form and open it in an appropriate editor.
2. Provide the patient's information. Enter the first name, middle initial, last name, date of birth, and gender in the designated fields. Ensure all details are accurate to avoid processing delays.
3. Fill in the patient's contact information, including street address, apartment number if applicable, city, state, zip code, and phone numbers. Indicate the primary contact method whether home or cell phone.
4. In the 'Member Health Plan/Insurer' section, input the health plan information. Include the provider's first name, last name, primary specialty, TIN, NPI number, and contact information.
5. Specify the diagnoses relevant to the patient. Use the provided coding system to detail the condition and include the start date for the request.
6. Select between initial care or continuing care. Provide relevant dates for evaluations and the onset of the condition.
7. Indicate the primary neurological condition from the specified categories. Ensure to check if the treatment is part of a Day Rehab program, and mention all services being provided, if applicable.
8. Complete the patient-reported/standardized assessment section, selecting the appropriate measures used for assessing mobility, balance, and daily living activities. Enter the scores in the provided fields.
9. Answer additional questions for conditions such as acquired brain injuries and Parkinson’s disease, providing details on cognitive impairments, functional status, and prior treatments as required.
10. Review the completed form for accuracy. Once satisfied, you can save changes, download a copy for your records, print the form for submission, or share it with relevant parties.

Take the first step towards securing therapy services by filling out the EviCore Healthcare PT/OT Therapy Intake Form online.