Follow the steps to complete the patient intake form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the facility or group name along with the TIN number and address where services will be provided. Include the facility’s NPI number, city, state, and contact person information.
3. Next, fill in the patient's basic information. Enter the patient’s last name, first name, patient ID, county, and date of birth in the specified format (mm/dd/yyyy).
4. Indicate the line of business by selecting an option such as Medicare, Medicaid, or Medicaid Healthy Kids, and specify the place of service by selecting between Office (11), Independent Clinic (49), or Other.
5. Move on to the diagnosis section where you will enter the ICD codes (1-4), primary diagnosis description, and relevant surgical history if applicable.
6. Complete the plan of care section by providing the approved frequency and duration of therapy. Indicate how many times per week and for how many weeks therapy will be needed.
7. If applicable, fill out the separate patient intake form for each discipline such as Physical Therapy, Occupational Therapy, or Speech Therapy, including test results and evaluation dates.
8. For extended episode fee requests, provide necessary details if continued therapy is required, including the number of visits scheduled and attended.
9. Lastly, review all provided information for accuracy, and ensure all necessary boxes are checked to confirm understanding and agreement to the terms.
10. Once you have completed the form, save changes, and you can opt to download, print, or share the completed form as needed.

Complete your patient intake form online today for a smoother start to your therapy journey.