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:Diagnosis, 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:Page 1 of 3PT/OT Treatment Request Clinical Worksheet Neurologic ConditionsDiagnosisCONFIDENTIALITY 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 ProviderFor NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. If there are any inconsistencies with the medical office records, please elaborate in the commentsection. Failure to provide all relevant information may delay the request. ationzauthori an submit to site the on located portal provider the into log also may You section.

3 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 | 1. Date of - Onset:Evaluation:Current findings:Member requires treatment for a different conditionAdditional care for same condition treated in the last 60 days3. What is the primary diagnosis?Cerebral PalsyStroke/CVAS pinal cord injuryParkinson's DiseaseTraumatic brain injury4. Are any comorbidities present?NoneStroke/CVAD iabetesCardiac DiseaseMultiple SclerosisOverweight > 100 lbsRheumatoid arthritisOther:5. What area(s) are affected?Right armRight legRight armLeft leg6. What is the muscle tone?NormalSpasticHypotonicHypertonic7. What is the pain level?/10 Unknown8. What is the pain frequency?0-25%26-50%51-75%76-100%Extern al/internal rotation <25 Not a problemNTFlexion/abduction <150 Extension loss >30 Flexion <130 NTPronation/supination <30 Not a problemFlexion <30 Extension <45 Not a problemUlnar dev <35 Radial dev <10 NTTotal active motion of any finger <210 Not a problemTotal active motion of thumb <30 NTAbduction <20 Flexion <125 NTExternal rotation <20 Not a problemFlexion <120 Extension loss >25 NTNot a problemDorsiflexion <15 Not a problemNTPlantarflexion <30 Arm functionNormal strengthRaises with flexed elbowUnablePage 2 of 3 Clinical Information 2.

4 Select any of the following which apply:Member not treated in the last 60 daysShoulderROME lbow ROMW rist ROMHand ROMHip ROMKnee ROMA nkle ROMeviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 | Arm functionReduced strength full rangeCan't move against gravityHand functionReduced strength full rangeFingertips don't reach palmNormal strengthNormal strengthRaises with bent kneeUnableStraight leg < 4/5 Can't lift against gravityWalks 20 assistive devicesHelp of another personWithout assistanceWheelchair boundSits without support9. Have there been recent falls?YesNo10. Is there risk for falls?YesNo11. What tests have been done?NoneTinetti:Berg Balance:Other:12. What is the interpretation of these tests?N/AHigh riskModerate riskLow riskYesNo14. Describe the patient's orientation:Person/place/timeCorrect for 1 of theseDisoriented15. Are there swallowing difficulties?

5 YesNo16. What is the patient's food consistency?Liquid dietNPOP ureedSolidThickened17. Describe any additional tests done:Test Name:Score:Interpretation:Test Name:Score:Interpretation:18. Has a home program been:InitiatedIndependentNoneBarriers to home program:19. What was the prior level of function?IndependentDependent20. What is the rehab potential?ExcellentGoodFairPoorActivity 1:Level:/10 Activity 2:Level:/10 Activity 3:Level:/1022. What is the percent of improvement since the start of care?%UnknownPage 3 of 3 Correct for 2 of these21. Patient Specific Functional Scale: Score 3 activities that the patient has the most difficulty performing. 0 isunable to perform, 10 is no a second treatment request, submit an additional form and fax both forms Information Leg functionGait/mobility13. Has a cognitive test, feeding, or other functional test been performed?

6 eviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 |