Physical Therapy Pre-Authorization Request Form
Patient Name
Date of Birth
Patient Phone
Member ID
Insurance Plan
Provider Name
Provider Phone
Provider Fax
Provider NPI
Facility Name
Diagnosis (ICD-10)
Requested Therapy Type
Physical Therapy
Occupational Therapy
Speech Therapy
Requested Number of Visits
Start Date
Clinical Rationale / Medical Necessity
Previous Treatment/Authorization (if any)