Get Fl Therapy Network Patient Intake Form 2019-2025

Completing the FL Therapy Network Patient Intake Form online is a straightforward process that ensures your therapy needs are accurately communicated. This guide provides you with clear, step-by-step instructions to help you fill out the form with confidence.

Follow the steps to successfully complete the intake form.

1. Click the ‘Get Form’ button to access the intake form and open it in your preferred editing platform.
2. Begin by providing the facility or group name at the top of the form. Next, enter the TIN number and the facility's address where the services will be provided, including city, state, and zip code.
3. Fill in the contact person’s name, phone number, and fax number. Also, provide the treating therapist’s name and NPI number along with the referring provider's name and NPI number.
4. Complete the patient information section by entering the patient's last name, first name, ID, county, and date of birth. Choose the line of business applicable for the patient, selecting from Medicare, Medicaid, or Medicaid Healthy Kids.
5. Specify the place of service by checking the appropriate box for 'Office,' 'Independent Clinic,' or 'Other.' Additionally, list any relevant ICD codes and provide the primary diagnosis description.
6. If applicable, indicate if the patient is status post-surgery by listing the procedure and the date of surgery. Also, include the date of any cerebral vascular accident (CVA). Remember to check the confirmation boxes when required.
7. Detail the member's plan of care, including the approved frequency and duration of therapy services. Specify how many times per week and for how many weeks the services will be provided.
8. If the patient requires services in multiple disciplines such as physical therapy, occupational therapy, or speech therapy, complete a separate patient intake form for each one.
9. After filling out all necessary fields, review the completed form for accuracy. Save your changes, and when ready, download, print, or share your completed intake form.

Start filling out the FL Therapy Network Patient Intake Form online to ensure a smooth therapy experience.