Can this authorization be e-signed?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are met. Verify payer acceptance of e-signatures and any required consumer disclosures for patient-facing records.

Is a physician signature always required?

Not always. Requirement depends on payer policy and state scope-of-practice rules. Some commercial plans accept therapist-signed requests; others require physician or PCP endorsement. Confirm payer-specific rules before submission.

What if the payer requests more information?

Respond promptly with dated progress notes, objective measures, or test results. Track the request date and communicate expected turnaround; timely responses improve approval chances and reduce care interruption.

How long does review typically take?

Review time varies by payer: many complete standard reviews in 7–14 days; expedited clinical reviews may occur within 24–72 hours for urgent cases. Document submission date to preserve appeal rights if needed.

What records should be retained?

Keep the signed authorization, supporting progress notes, and submission evidence. For healthcare, retain records at least six years as per HIPAA (45 CFR §164.530(j)), and follow state-specific retention rules.

Can I submit a retrospective authorization?

Some payers permit retrospective review but require stronger documentation and justification. Anticipate higher denial risk and consider contemporaneous documentation whenever possible.

Electronic Signature
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Authorization Request for Additional Physical Therapy

Authorization Request for Additional Physical Therapy

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

AUTHORIZATION REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATMENT

PLEASE TYPE OR PRINT AND PROVIDE ALL OF THE INFORMATION REQUESTED

Claim Number

REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATMENT

Name of Injured Employee

SSN#

Date of Injury

Name of Employer

Name of Treating Physician

Date of Last Treatment

Number of Treatments Since Injured's First Visit

DESCRIBE THE PRESENT CONDITION OF THE INJURED EMPLOYEE (Include Your Objective Findings, Symptoms, and Patient Complaints)

DEFINE AND GIVE THE NUMBER OF ADDITIONAL TREATMENTS FOR WHICH AUTHORIZATION IS REQUESTED:

Give the Date By Which the

Treatment Will Be Completed

If Authorization is Granted:

MUST PROVIDE NEW PRESCRIPTION WITH EACH ADDITIONAL TREATMENT REQUEST

Date

Signature and Address of Physical Therapist

Telephone Number

P.T.

FOR INSURER'S ACTION

AUTHORIZATION IS GRANTED FOR ADDITIONAL P.T. TREATMENTS

Other Action:

Authorization for Additional Physical Therapy Treatment is Denied. Treating Physician Will Be Consulted in this case.

Date

Signature

Title

D-33 (rev. 7/99)

What an Authorization Request for Additional Physical Therapy Is

An Authorization Request for Additional Physical Therapy is a formal clinical and administrative document used to request approval from a payer, utilization review organization, or internal managed care team to extend physical therapy beyond an originally authorized course. The form typically summarizes the patient’s clinical status, progress to date, objective findings, functional limitations, treatment delivered, measurable goals, and a rationale for continued care. It serves both as a clinical justification for services and as a billing prerequisite for reimbursement, prior authorization, or utilization management.

Why completing a clear authorization matters

A well-prepared request reduces claim denials, speeds review, and documents medical necessity under payer rules and clinical standards. It clarifies the expected therapy type, frequency, and duration and aligns provider, patient, and payer expectations while preserving audit-ready records under HIPAA and payer policies.

Who prepares and who reviews this authorization

Typical participants in the authorization process include treating physical therapists, medical directors, case managers, billing staff, and payer reviewers.

Treating physical therapist — documents clinical findings, treatment plan, progress notes, objective measures and ongoing goals.
Case manager / utilization reviewer — evaluates medical necessity, payer policy alignment, and coordinates approvals or denials.
Medical provider (if required) — signs or co-signs when physician authorization is necessary for ongoing therapy.

Responsibility for submission and follow-up typically rests with the treating therapist or administrative staff; retention of a signed copy meets audit and compliance requirements.

Signatory roles and typical submitters

Treating Therapist

The licensed physical therapist documents objective findings, treatment provided, progress toward measurable goals, and signs or electronically executes the request per facility policy. The therapist’s clinical narrative forms the primary medical-necessity justification during payer review and must match charted progress notes.

Medical Director

A physician or advanced practice clinician may be required to review and sign when payer rules or state scope of practice mandates physician authorization; their endorsement links the plan of care to the supervising medical decision-maker.

Core sections to include in a professional authorization

A complete request is structured to allow rapid clinical review: it should contain patient and provider identifiers, a succinct clinical summary, objective measures, treatment history, specific request details, and signature/attestation fields.

Patient Details

Full name, DOB, member ID, payer, and contact information to match claim and eligibility records.

Clinical Summary

Brief history, current status, relevant comorbidities, and prior interventions that affect therapy decisions.

Objective Measures

Range of motion, strength grades, functional scales (e.g., DASH, Oswestry), and baseline/most recent scores.

Treatment History

Dates of services, modalities used, progress notes, and response to prior PT sessions.

Requested Services

Specific CPT/HCPCS codes, frequency per week, expected number of additional visits, and anticipated end date.

Rationale

Clear medical-necessity statement tying objective findings to expected functional gains and a plan to measure outcomes.

Required data elements to include

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

Insurance ID: Payer/member number

Diagnosis Codes: ICD-10 codes

Requested CPT: Procedure codes

Provider Info: NPI and clinic address

Step-by-step: submitting an authorization request

Follow a clear sequence to prepare, document, and submit the supporting materials for efficient payer review.

01

Compile records: Gather chart notes, objective measures, and prior authorization history
02

Complete form: Fill patient, provider, diagnosis, CPT, and requested sessions
03

Attach evidence: Attach recent progress notes, test results, and functional assessments
04

Submit and track: Send to payer portal or fax and record submission date

Configuring an online authorization workflow

Set up fields, attachments, and routing so each request follows a repeatable, auditable path for clinical and administrative reviewers.

Field	Configuration
Patient ID	Required, validated against insurance number
Diagnosis Code	Mandatory; single-select ICD-10 list
Attachments	Allow PDF upload; require at least one progress note
Routing	Auto-route to utilization review and billing

Digital submission and platform considerations

Electronic submission should support secure uploads, complate audit trails, and optional signer authentication for clinician attestation.

File formats: PDF or DOCX preferred
Authentication: Email, SMS code, or two-factor
Integrations: EHR and payer portals supported

Confirm the chosen vendor supports HIPAA compliance and produces an exportable audit trail that documents signer identity, timestamps, and attachment history.

Typical routing: where the authorization goes

Understanding destination paths reduces rework and clarifies who will action the request after submission.

Payer Portal: Submitted directly to insurer utilization review
Fax or Secure Email: Used when portals are unavailable
Internal UM Team: Facility case management triages requests
Third-Party Reviewer: External medical reviewers may be assigned

Timelines, deadlines, and common processing expectations

Timelines vary by payer and state; track submission date, expected review window, and appeal deadlines to protect patient access.

Initial review window:

Payers often respond within 7–14 calendar days

Urgent requests:

Expedited reviews available within 24–72 hours

Appeal deadline:

Varies by plan; note payer-specific timeline

Retrospective requests:

Premium documentation required for retro approvals

Record keeping:

Document submission and communication timestamps

Key processing milestones for an authorization request

Track discrete milestones from preparation through final determination to manage expectations and appeals.

01

Prepare Documentation

Collect notes, assessments, and prior authorization history

02

Complete Request

Populate form fields and attach supporting records

03

Submit to Payer

Send via portal, secure email, or fax and log date

04

Receive Determination

Payer issues approval, denial, or request for more info

Common mistakes to avoid

Incomplete objective data delaying medical-necessity approval
Mismatched patient identifiers causing eligibility failures
Missing signature or improper attestation invalidating the request
Incorrect CPT or ICD coding leading to claim denials

Risks and potential consequences of incorrect requests

Denied Payment: Care not reimbursed

Claim Audits: Increased audit risk and recovery

Treatment Delay: Patient access interrupted

HIPAA Exposure: Breach risk from improper handling

Compliance Findings: Internal or payer sanctions

Appeal Burden: Additional administrative work

eSignature vendor comparison for submitting this authorization

Compare basic commercial eSignature options for secure, auditable submission workflows; signNow is listed first per vendor comparison conventions.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about authorization requests

Answers to common questions about electronic signing, timing, and documentation for additional physical therapy requests.

Need help? Contact support

Can this authorization be e-signed?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are met. Verify payer acceptance of e-signatures and any required consumer disclosures for patient-facing records.
Is a physician signature always required?
Not always. Requirement depends on payer policy and state scope-of-practice rules. Some commercial plans accept therapist-signed requests; others require physician or PCP endorsement. Confirm payer-specific rules before submission.
What if the payer requests more information?
Respond promptly with dated progress notes, objective measures, or test results. Track the request date and communicate expected turnaround; timely responses improve approval chances and reduce care interruption.
How long does review typically take?
Review time varies by payer: many complete standard reviews in 7–14 days; expedited clinical reviews may occur within 24–72 hours for urgent cases. Document submission date to preserve appeal rights if needed.
What records should be retained?
Keep the signed authorization, supporting progress notes, and submission evidence. For healthcare, retain records at least six years as per HIPAA (45 CFR §164.530(j)), and follow state-specific retention rules.
Can I submit a retrospective authorization?
Some payers permit retrospective review but require stronger documentation and justification. Anticipate higher denial risk and consider contemporaneous documentation whenever possible.

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