Transcription of BCBS IL PT Request Form-2013 (59008 - Activated, …
1 Copyright 2 015 OrthoNet, LLCASP For Internal Office Use Only Initial Evaluation Date//MonthDayYearREQUEST INFORMATION: Request for:Onset (Commencement) of Therapy ServicesExtension of Therapy ServicesOther Procedure: _____Service Type:Physical TherapyOccupational TherapyIs this Request for post-operative therapy visits?YesNoPATIENT INFORMATION:MonthDayYearDate of Birth//Last NameFirst NameNOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL you receive this material/information in error, please contact the sender and delete or destroy the : 1. Use this form when requesting prior authorization of therapy services for BCBSIL Please complete and Fax this Request form along with all supporting clinical documentation to OrthoNet at 1-888-875-9481. (This completed form should be page 1 of the Fax.)
2 3. Please ensure that this form is a DIRECT COPY from the Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where For assistance in completing this form , please call OrthoNet provider services toll free at AddressFacility or Provider NameCityFax Number*()-Telephone Number()-* The above fax number will be used to confirm your address/location ifwe are unable to contact you using the fax number on file with fax to OrthoNet at: 1-888-875-9481 Therapy Fax Request FormFax Date: _____# of Pages Faxed: _____THERAPY PROVIDER INFORMATIONA Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield AssociationIndividual NPI NumberFacility NPI NumberIndividual Tax ID NumberFacility Tax ID NumberBCBSIL Member ID NumberProvider Tax ID NumberBilling National Provider Identifier (NPI)Diagnosis Code(ICD-10 Format)5900859008
