Follow the steps to accurately complete the form online.

1. Click the ‘Get Form’ button to access the worksheet and open it in your preferred editor.
2. In the rendering provider information section, fill in the therapist's last name and first name, the name of the group or facility, and the complete address including city, state, and zip code.
3. Next, provide the billing provider tax identification number (TIN), along with the phone number and National Provider Identifier (NPI) for the billing provider.
4. In the patient information section, accurately enter the patient's last name, first name, date of birth, and their complete mailing address.
5. Fill in the member ID as shown on the patient's insurance card, the payor name from the insurance, and the primary subscriber's (policyholder's) name and phone number.
6. For the clinical information section, input the primary ICD/diagnosis code and its description. Ensure that the start date of the request is within 7 days.
7. Indicate whether the member has received treatment for the same condition in the last 60 days and provide the date of the initial evaluation and date of onset.
8. Select the primary area treated and any comorbidities from the provided options. Indicate if the treatment is post-surgical and complete any required details regarding the surgery.
9. Document the range of motion (ROM) measurements if they are not within normal limits for the primary area treated, as well as strength measurements if necessary.
10. In the pain section, indicate any changes since the start of care. Include optional information on activities the patient has difficulty performing and their improvement percentage.
11. Once all sections are completed, save your changes. You can download, print, or share the form as needed.

Complete your documents online to ensure timely processing and care.