Get NJM Insurance AC-PIP17w 2016-2024

ATTENDING PROVIDER TREATMENT PLAN INITIAL SUBMISSION TYPE OR PRINT LEGIBLY FOLLOW-UP SUBMISSION CLAIM DATE SUBMITTED PATIENT INFORMATION 12. DATE OF ACCIDENT First 3. CITY Last 13. IS PATIENT S CONDITION RELATED TO 17. CITY 9. S*S* NUMBER YES 10. INSURANCE COMPANY 20. ZIP CODE NO C. OTHER ACCIDENT F 18. STATE 19. TELEPHONE Include Area Code M Initial 8. SEX 16. POLICYHOLDER S ADDRESS No* Street 4. STATE A. EMPLOYMENT 7. PATIENT BIRTHDATE Year 2. PATIENT S ADDRESS No* Street Day POLICYHOLDER INFORMATION if different 1. PATIENT S NAME Month 21. RELATIONSHIP TO PATIENT 14. IS PATIENT UNABLE TO WORK 11. POLICY NUMBER PROVIDER INFORMATION 22. NAME OF TREATING PROVIDER 23. TAX I.D. NUMBER 24. SPECIALTY 25. FACILITY OR OFFICE NAME 26. FACILITY/OFFICE ADDRESS No* Street 31. EMAIL ADDRESS 32. FAX Include Area Code 33. INITIAL DATE OF TX 34. DATE OF LAST VISIT 35. PATIENT MEDICAL HISTORY. HAS PATIENT EVER HAD ANY OF THE FOLLOWING SERVICES CHECKMARK THOSE APPLICABLE BELOW* NOTE-ALL BOXES CHECKED REQUIRE A BRIEF DESCRIPTION OF SERVICE AND DATE PROVIDED ON SEPARATE ATTACHMENT ALL MEDICATION MRI 36. PRIMARY DIAGNOSIS ICD-9 SURGERY X-RAY 37. SECONDARY DIAGNOSIS ICD-9 DIAGNOSTICS TESTING 38. ADDITIONAL DIAGNOSIS ICD-9 OTHER PROPOSED COURSE OF TREATMENT AS IT RELATES TO THIS MVA 40. DATE S OF TREATMENT REQUESTED FROM 41. CHECK APPROPRIATE CARE PATH If applicable TO CP1 CP2 CP3 CP4 CP5 CP6 42. REQUEST FOR SERVICES CPT / HCPS / NDC CODES Use left box for single codes or left and right box for a range of codes FREQUENCY Times per visit Visits per week DURATION Number of weeks TOTAL UNITS 42. CHECKMARK ATTACHMENTS BELOW* NOTE-ALL SUPPORTING DOCUMENTS CHECKED MUST BE PROVIDED ON SEPARATE ATTACHMENT SOAP NOTES PROGRESS NOTES TEST RESULTS MEDICAL HISTORY PRESCRIPTIONS FRAUD PREVENTION-NEW JERSEY WARNING ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES* PROVIDER STATEMENT I HAVE PERSONALLY COMPLETED AND REVIEWED THIS FORM. THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF* SIGNATURE OF PROVIDER AC-PIP17w 7/06 DATE ATPT Form Version 1.1 9/2004.