Physical Medicine Treatment Plan

(for anticipated services over 20 visits)

Do not print; for electronic submission only.

NOTE: All fields are required. If a field is not applicable, mark it with N/A.

Patient and Illness Information
Patient's First Name (as it appears in EVBI):
Patient's Last Name:
ID #:
DOB: (mm/dd/yyyy)
Male
Female
Occupation:

Diagnosis:

ICD-9 and Description:

Mode of Onset:
Accident
Illness
Injury
Work Related
Other
Describe Mode of Onset:
Episode of Care
Date of Onset: (mm/dd/yyyy)
Date patient first visited you: (mm/dd/yyyy)

 

For this condition, number of times this calendar year patient visited:
1) you
2) another provider within your organization
3) a provider outside of your organization

 

List other condition previous treated:

For other conditions, number of times this calendar year patient visited:
1) you
2) another provider within your organization
3) a provider outside of your organization

 

Subjective complaints at the initial visit and most recent re-evaluation:

Initial Numeric Pain Rating Scale (NRPS): 0 = No Pain; 10 = Unbearable Pain
Current Numeric Pain Rating Scale (NRPS): 0 = No Pain; 10 = Unbearable Pain
How does the patient describe his/her overall improvement since the intial visit in this episode of care? 0% = None; 100% = Fully Recovered
Examination findings at the initial visit and most recent re-evaluation:
Initial restrictions of activities of daily living/Functional Index: 0 = No Limitations; 10 = Totally Disabled
Current restrictions of activities of daily living/Functional Index: 0 = No Limitations; 10 = Totally Disabled
Diagnostic testing, imaging results, complicating factors:
Dates and descriptions of exacerbations:
Physical work capabilities at the initial visit:
Physical work capabilities at the current visit:
Treatment provided including home care and coordination with other specialists:
Goals/objectives/prognosis and rationale for additional care:
Have you submitted previous Treatment Plans for this patient and condition this year?
Yes, If additional visits were approved, please specify how many:
No
Requested Care
Type:
PT
OT
DC
DO/MD/PA/DPM
Modalities/Procedures:
Anticipated Frequency & Duration:

Anticipated Dates of Care: (cannot be more than 7 days past)
From - (mm/dd/yyyy)
To - (mm/dd/yyyy)

Provider Information
Provider Name:
NPI (National Provider Identifier): (Note: For facilities such as hospital outpatient departments, use the facility provider name and NPI; for group practices, use the individual providerís NPI. The provider's NPI number and provider name must match our records.)
Return Address:
Phone Number:
Fax Number:
Do you practice in Iowa or South Dakota?
Iowa
South Dakota
E-mail Address:

Retype E-mail Address:

Please check the box acknowledging that you have read the following: Approvals are subject to the benefits, terms, conditions, and limitations outlined in the patient's benefits contract. This review is for medical necessity only, and is not a review of the member's benefits. Please see Wellmark.com for member benefit information.

    

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
 
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