Physical Medicine Treatment Plan

Please use this form when anticipated services are expected to exceed 20 visits.

Please do not print this form; it is for electronic submission only. For other inquiries, please use the secure Ask & Track a Question  tool.

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-10 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 of Iowa, Wellmark Health Plan of Iowa, Inc., Wellmark Blue Cross and Blue Shield of South Dakota, Wellmark Synergy Health, Inc., and Wellmark Value Health Plan, Inc. are independent licensees of the Blue Cross and Blue Shield Association.
 
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