Transcription of Month Day Year TYPE OR PRINT LEGIBLY - New …
1 MonthDayYearInitialInitial4. STATE17. STATE M FFirstInitial28. STATEOTHERICD CHECK APPROPRIATE CARE PATH (if applicable) PROPOSED COURSE OF TREATMENT AS IT RELATES TO THIS MVAP urchaseRentalINCLUDE SUPPORTING DOCUMENTS391. PATIENT'S NAME14. POLICYHOLDER'S NAMELast First35. PATIENT MEDICAL HISTORY. HAS PATIENT EVER HAD ANY OF THE FOLLOWING SERVICES? CHECKMARK THOSE APPLICABLE BELOW. (*NOTE-ALL BOXES CHECKED REQUIRE A BRIEF DESCRIPTION OF SERVICE AND DATE PROVIDED ON SEPARATE ATTACHMENT) MEDICATIONSMRISURGERY15. POLICYHOLDER'S ADDRESS (No. Street)19. ZIP CODE7. PATIENT BIRTHDATE8. SEXATTENDING PROVIDER TREATMENT PLANSIGNATURE OF PROVIDERDATE9. INSURANCE COMPANY(Explain Unusual Circumstances)TOMMDDYYMM34. DATE OF LAST VISITINITIAL SUBMISSION FOLLOW-UP SUBMISSION10. POLICY NUMBER YESDATE SUBMITTEDPATIENT INFORMATIONPOLICYHOLDER INFORMATION (if different)TYPE OR PRINT LEGIBLYCLAIM #: 11.
2 DATE OF ACCIDENTLast 2. PATIENT'S ADDRESS (No. Street)6. TELEPHONE # (Include Area Code)B. AUTO ACCIDENT?C. OTHER ACCIDENT?3. CITY YES NO YES NOPROVIDER INFORMATIONLast 22. TAX NPI24. SPECIALTY25. FACILITY OR OFFICE NAME13. IS PATIENT UNABLE TO WORK? NO YESA. EMPLOYMENT?12. IS PATIENT'S CONDITION RELATED TO:DURATION (# of weeks)TOTAL UNITS DIAGNOSIS POINTEREQUIPMENTSPINAL INJECTIONU nilateralPROCEDURES, SERVICES OR SUPPLIESB ilateral20. RELATIONSHIP TO PATIENTDIAGNOSTIC TESTEXISTING CONDITIONSCOMORBIDITIES36. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate A-L to service line below using Diagnosis Pointer in section 38 below)X-RAY26. FACILITY /OFFICE ADDRESS (No. Street)27. CITY29. ZIP CODE30. TELEPHONE # (Include Area Code)31. EMAIL FAX # (Include Area Code)33. INITIAL DATE OF APTP FORM VERSION (3/2016)FRAUD PREVENTION - NEW JERSEY WARNING ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL STATEMENT I HAVE PERSONALLY COMPLETED AND PREVIEWED THIS FORM.
3 THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND (Visits per week) CP1 CP2 CP3 CP4CP5CP6 FROMFREQUENCY (Times per visit)First38. DATE(S) OF REQUEST5. ZIP CODE16. CITY18. TELEPHONE # (Include Area Code) NO21. NAME OF TREATING PROVIDERB.
