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Physical Therapy Treatment Authorization Fax Request F248-055-000 - Washington

Physical Therapy Treatment Authorization Fax Request Form. This is a Washington form and can be used in Claims Workers Comp .
 Fillable pdf Last Modified 12/10/2012
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Mail to: L&I Provider Hotline PO Box 44291 Olympia, WA 98504-4291 Phone 800-848-0811 Fax 360-902-6490 Occupational or Physical Therapy Treatment Authorization Fax Request Use this form to request continuing authorization for occupational or physical therapy services. Requests for services beyond 24 visits must be sent to Qualis Health (800-541-2894). 1. Provider information Therapy clinic business name Phone number at therapy clinic Contact name Fax number at therapy clinic 2. Worker information Worker name Referring physician name Claim number Side and area of body being treated 3. Authorization request information Occupational therapy Physical therapy To date number of visits in your clinic: ______ Requested number of visits ______ for dates ____________ through ____________. (Use the mm/dd/yyyy format.) I would like to receive the department's response with a fax. I would like to receive the department's response with a phone call. 4. Signature I certify that the worker is showing progress during therapy treatment. The referring physician has recommended continuing therapy treatment and documentation has or will be sent to the department. An initial evaluation report has or will be sent to the department. Progress reports required by the department have or will be sent. Treatment being provided is for the effects of the industrial injury. Provider's signature 5. Department response Claim has ______ visits as of ____________. ______ visits are authorized. Request has been referred to the Claim Manager. Utilization review (UR) is required. Contact Qualis Health at 800-541-2894. This is a self-insured claim. Contact: ____________________________________. Additional information: Completed by: Date: INDEX: MED American LegalNet, Inc. F248-055-000 Occupation Physical Therapy treatment authorization fax request 08-2012
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