Get Evicore Healthcare Pt/ot Therapy Intake Form: Neurological Conditions 2018

Filling out the EviCore Healthcare PT/OT Therapy Intake Form for neurological conditions online can seem daunting. This guide provides clear instructions to help you navigate each section of the form with confidence and ease.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the intake form and open it in your preferred editing application.
2. Begin by entering the patient's first name, middle initial, last name, and date of birth in the appropriate fields. Make sure to follow the required format for the date.
3. Fill in the patient's gender, street address, apartment number (if applicable), city, state, and zip code. Include both home and cell phone numbers, selecting the preferred contact method.
4. Provide the member ID and the name of the member's health plan or insurer. This information assists in identifying the patient's insurance provider.
5. Complete the provider information section by entering the provider's first name, last name, specialty, TIN, NPI, and contact details including phone, fax, and email.
6. In the administrative section, indicate the diagnosis codes along with their descriptions and the date for the request. Specify whether it is an initial or continuing care request.
7. Select the primary neurological condition from the list provided. Include any other pertinent conditions and treatment services being requested.
8. Complete the patient-reported or standardized assessments section by selecting the appropriate measures used. This is crucial for authorizing care.
9. For follow-up requests, answer the additional questions regarding the patient's response to care and any factors affecting their progress.
10. Review all entered information for accuracy before saving the completed form. You can download, print, or share the form as needed.

Complete the EviCore Healthcare PT/OT Therapy Intake Form online today!