Transcription of Physical/Occupational/Massage Therapy Provider …
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Physical/Occupational/Massage Therapy Provider …
PO Box 44291 Olympia WA 98504-4291 Phone: 800-848-0811 Fax: 360-902-6490 Physical/Occupational/Massage Therapy Provider hotline Service authorization request Provider Information Therapy Clinic/Business Name Contact Name Phone number at Therapy clinic Fax number at Therapy clinic Worker Information Worker name Claim number Right Left Referring physician name Area of body being treated request Information occupational Therapy physical Therapy massage Therapy To date number of visits in your clinic: _____ Requested number of visits _____ for dates _____ through _____.
PO Box 44291 . Olympia WA 98504 -4291 . Phone: 800-848-0811 Fax: 360-902-6490 Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request
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