Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the facility or group name in the designated field. Follow this by providing the TIN number, facility or group address, and NPI number. Make sure the information is accurate to avoid delays.
3. In the contact information section, fill out the city, state, and zip code. Include the contact person's name, phone, and fax number so that inquiries can be directed properly.
4. Provide the treating therapist's name and their NPI number. Include the referring provider's name and NPI number as well, ensuring all fields are filled accurately.
5. Enter the patient's last name, first name, and patient ID. Additionally, fill in the patient's county and date of birth in the specified format (mm/dd/yyyy).
6. Select the line of business applicable to the patient: Medicare, Medicaid, or Medicaid Healthy Kids. Make sure to choose the correct option.
7. Indicate the place of service by selecting from the provided options: Office (11), Independent Clinic (49), or specify 'Other' with details if applicable.
8. Fill in the appropriate ICD codes and primary diagnosis description. If the patient has undergone surgery, include the date and the procedure information.
9. For cerebral vascular accidents, specify the date of the CVA. Confirm details by checking the necessary boxes provided in the form.
10. Complete the plan of care section, detailing the frequency and duration of therapy. Specify the number of sessions per week and the total number of weeks.
11. Indicate any tests used and the corresponding test scores in the provided fields. Include any supplementary notes or comments that may be relevant.
12. Finally, review all entered information for accuracy. Once complete, you can save changes, download, print, or share the form as needed.

Start filling out your FL Therapy Network Patient Intake Form online today to ensure a smooth therapy initiation process.