Authorization Request For Additional Physical Therapy Treatment {D-33}

AUTHORIZATION REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATMENT PLEASE TYPE OR PRINT AND PROVIDE ALL OF THE Claim Number INFORMATION REQUESTED REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATMENT Name of Injured Employee SSN# Date of Injury Name of Employer Name of Treating Physician Date of Last Treatment Number of Treatments Since Injureds First VisitDESCRIBE THE PRESENT CONDITION OF THE INJURED EMPLOYEE (Include Your Objective Findings, Symptoms, and Patient Complaints) DEFINE AND GIVE THE NUMBER OF ADDITIONAL TREATMENTS FOR WHICH AUTHORIZATION IS REQUESTED: Give the Date By Which the Treatment Will Be Completed If Authorization is Granted: MUST PROVIDE NEW PRESCRIPTION WITH EACH ADDITIONAL TREATMENT REQUEST Date Signature and Address of Physical Therapist Telephone Number P.T. FOR INSURERS ACTION [ ] AUTHORIZATION IS GRANTED FOR [ ] Authorization for Additional Physical Therapy ADDITIONAL P.T. TREATMENTS Treatment is Denied. Treating Physician Will Be Consulted in this case. [ ] Other Action: Date Signature Title D-33 (rev. 7/99)