Get PSF-750 2015-2024

Instructions Patient Summary Form Please complete this form within the specified timeframe. All PSF submissions should be completed online at www. Myoptumhealthphysicalhealth. com unless otherwise instructed. PSF-750 Rev 7/1/2015 Patient Information Female Patient name Last First Please review the Plan Summary for more information. Male MI Patient date of birth City Patient address State Patient insurance ID Health plan Referring physician if applicable Date referral issued if applicable Zip code Group number Referral number if applicable Provider Information 1. Name of the billing provider or facility as it will appear on the claim form 2. Federal tax ID TIN of entity in box 1 MD/DO 4 OT 5 Both PT and OT 6 Home Care 7 ATC DC 3 PT 8 MT 9 Other 3. Name and credentials of the individual performing the service s 4. Alternate name if any of entity in box 1 6. Phone number 5. NPI of entity in box 1 8. City 7. Address of the billing provider or facility indicated in box 1 Provider Completes This Section Cause of Current Episode Patient Type 1 Traumatic 4 Post-surgical 2 Unspecified 5 Work related 3 Repetitive 6 Motor vehicle 1 ACL Reconstruction 3 Tendon Repair Est d new injury Est d new episode 5 Joint Replacement Est d continuing care DC ONLY 2 Recurrent multiple episodes of 3 months 98940 98942 Neck Index DASH 98941 98943 Back Index LEFS other FOM 3 Chronic continuous duration 3 months Patient Completes This Section Current Functional Measure Score Anticipated CMT Level 1 Initial onset within last 3 months 2 Rotator Cuff/Labral Repair 4 Spinal Fusion Nature of Condition Please ensure all digits are entered accurately Type of Surgery New to your office Diagnosis ICD codes Date of Surgery Date you want THIS submission to begin Indicate where you have pain or other symptoms Symptoms began on Please fill in selections completely 1. Briefly describe your symptoms 2. How did your symptoms start 3. Average pain intensity Last 24 hours no pain worst pain Past week no pain 4. How often do you experience your symptoms 1 Constantly 76 -100 of the time Frequently 51 -75 of the time 3 Occasionally 26 - 50 of the time 4 Intermittently 0 -25 of the time 5. How much have your symptoms interfered with your usual daily activities including both work outside the home and housework 1 Not at all 2 A little bit Moderately 4 Quite a bit Extremely 6. How is your condition changing since care began at this facility 0 N/A This is the initial visit 1 Much worse 2 Worse 3 A little worse 4 No change 5 A little better 7. In general would you say your overall health right now is. Excellent Patient Signature X Very good Good 4 Fair 5 Poor Date Better Much better. Name of the billing provider or facility as it will appear on the claim form 2. Federal tax ID TIN of entity in box 1 MD/DO 4 OT 5 Both PT and OT 6 Home Care 7 ATC DC 3 PT 8 MT 9 Other 3. Name and credentials of the individual performing the service s 4. Alternate name if any of entity in box 1 6. Name and credentials of the individual performing the service s 4. Alternate name if any of entity in box 1 6. Phone number 5. NPI of entity in box 1 8. City 7. Address of the billing provider or facility indicated in box 1 Provider Completes This Section Cause of Current Episode Patient Type 1 Traumatic 4 Post-surgical 2 Unspecified 5 Work related 3 Repetitive 6 Motor vehicle 1 ACL Reconstruction 3 Tendon Repair Est d new injury Est d new episode 5 Joint Replacement Est d continuing care DC ONLY 2 Recurrent multiple episodes of 3 months 98940 98942 Neck Index DASH 98941 98943 Back Index LEFS other FOM 3 Chronic continuous duration 3 months Patient Completes This Section Current Functional Measure Score Anticipated CMT Level 1 Initial onset within last 3 months 2 Rotator Cuff/Labral Repair 4 Spinal Fusion Nature of Condition Please ensure all digits are entered accurately Type of Surgery New to your office Diagnosis ICD codes Date of Surgery Date you want THIS submission to begin Indicate where you have pain or other symptoms Symptoms began on Please fill in selections completely 1. .