er emb mm/dd/yyyy - eviCore

1 First Name:Middle I nitial:Last Name:DOB ( mm/dd/yyyy ):Gender:MaleFemaleStreet Address:Apt #:City:State:Zip:Cell P hone:Primary Contact:HomeCellHealth Plan:Member ID:Group I D:First Name:Last Name:Primary S pecialty:TIN:NPI:Physician P hone:Physician Fax:Address:Suite #:City:State:Zip:Office Contact:Ext:Contact Email:First Name:Last Name:Group/Site Name:Primary S pecialty:TIN:NPI:Site Phone:Site Fax:Address:Suite #:City:State:Zip:*Note: Separate forms must be submitted for P T and O T r , i f k nown or r ule out:ICD-10 Codes:PTOTR eference/Auth Number ( if c ontinued c are):Date of l ast v isit:Start date of th is r equest:Date of - Onset:Initial Evaluation:Current f indings:Page 1 of 3 DiagnosisCONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacyregulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

2 This information is intended only for the use of the recipient(s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that anydisclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you havereceived this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without savingthem in any Phone:Ordering ProviderPT/OT Treatment Request Clinical Worksheet Pediatric DevelopmentalFor NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. Ifthere are any inconsistencies with the medical office records, please elaborate in the commentsection. Failure to provide all relevant information may delay the request.

3 Authorization an submit to site the on located portal provider the into log also may You section. Forms Fax and Guidelines the under on found be can numbers fax and URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE . eviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 | Member requires treatment for a different conditionAdditional care for same condition treated in the last 60 days2. What is the primary diagnosis?Cerebral palsyAutism Spectrum DisorderDevelopmental delayOther:3. Has there been previous treatment for this condition?Yes No4. Has there been surgery for this conditon?Yes NoIf yes, what was the date and type of surgery?5. Describe any standardized tests taken:Test Name:Interpretation:Test Name:Interpretation:Test Name:Interpretation:Age appropriateNot testedNot age appropriateNot testedNot age appropriateUnable to negotiate stairsRequires wheelchairAge appropriateNot testedNot age appropriateImpairedAge appropriateNot testedNot age appropriateDoes not limit functionNot testedLimits voluntary movementContracture presentSpasticity limits functionAge appropriateNot testedInadequate for most functional tastsGenerally hypotonicAge appropriate ImpairedNot testedAge appropriate ImpairedNot testedAge appropriateNot testedNot age appropriatePage 2 of 3 Motor planningBalance and postureROM/flexibility StrengthClinical Information Visual-motor skillsSelf-carePerceptual ability1.

4 Select any of the following which apply:Member not treated in the last 60 daysAmbulate independently with/without assistive deviceFine motor skills assessment (handwriting, object manipulation, etc.)LocomotioneviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 | Age appropriateNot testedNot age appropriateAge appropriateNot testedNot age appropriateAge appropriateNot testedNot age appropriateNot establishedIndependentInitiatedBarriers to home program6. Describe any barriers to the home program:7. What are the goals of therapy? Select all that devicesStrengthDevelopment/functionHome programSensory/motorMotion/flexibilitySe lf-care8. What progress has been made towards these goals?All goals metMore than 50% progressLess than 50% progressNo progress toward goals9. In what areas have goals been progressed?StrengthSensory/motor developmentSelf-care abilityHome program10. Describe progress towards goals:*If this request is for home health treatment, answer the following questions:11.

5 Please indicate homebound reason:Assistance required for ambulationDependent on adaptive devicesUnable to safely leave home unassistedMedical restriction(s)Other:12. Indicate living situation:Caregiver availableNo caregiver available Limited caregiver supportUnknown caregiver supportPage 3 of 3 Clinical Information Play skillsSocial abilityOral-motor feedingHome programFor a second treatment request, submit an additional form and fax both forms together. Additional information/comments: eviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 |