| Patient and Illness Information |
Patient's First Name:
(as it appears in EVBI)
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Patient's Last Name:
(as it appears in EVBI)
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ID #:
(three alpha characters followed by Wellmark ID)
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DOB: (mm/dd/yyyy)
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Male
Female |
Occupation:
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Diagnosis:
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ICD-10 and Description:
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Mode of Onset:
Accident
Illness
Injury
Work Related
Other |
Describe Mode of Onset:
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| Episode of Care |
Date of Onset: (mm/dd/yyyy)
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Date patient first visited you: (mm/dd/yyyy)
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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
|
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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:
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Initial Numeric Pain Rating Scale (NRPS): 0 = No Pain; 10 = Unbearable Pain
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Current Numeric Pain Rating Scale (NRPS): 0 = No Pain; 10 = Unbearable Pain
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How does the patient describe his/her overall improvement since the intial visit in this episode of care? 0% = None; 100% = Fully Recovered
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Examination findings at the initial visit and most
recent re-evaluation:
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Initial restrictions of activities of daily living/Functional Index: 0 = No Limitations; 10 = Totally Disabled
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Current restrictions of activities of daily living/Functional Index: 0 = No Limitations; 10 = Totally Disabled
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Diagnostic testing, imaging results, complicating
factors:
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Dates and descriptions of exacerbations:
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Physical work capabilities at the initial visit:
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Physical work capabilities at the current visit:
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Treatment provided including home care and coordination
with other specialists:
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Goals/objectives/prognosis and rationale for additional
care:
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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:
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Anticipated Frequency & Duration:
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Anticipated Dates of Care: (cannot be more than 7 days past or 14 days in the future)
From - (mm/dd/yyyy)
To - (mm/dd/yyyy)
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| Provider Information |
Provider Name:
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NPI (National Provider Identifier - (Note: For facilities such as hospital outpatient departments, use the facility NPI; for group practices, use the individual provider’s NPI. The provider's NPI number must match our records.)):
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Return Address (include city, state, zip):
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Phone Number:
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Do you practice in Iowa or South Dakota?
Iowa
South Dakota |
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E-mail Address:
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Retype E-mail Address:
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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. |
tool.