Fill and Sign the Authorization Request for Additional Physical Therapy Form

AUTHORIZATION REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATM ENT PLEASE TYPE OR PRINT AND PROV IDE ALL OF THE Claim Number INFORM ATION REQUESTED REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATM ENT Name of Injured Employ ee SSN#Dat e of Injury Name of Employ er Name of Treat ing Phy sician Dat e of Last Treat mentNumber of Treat ment s Since Injured' s First V isit DESCRIBE THE PRESENT CONDITION OF THE INJ URED EM PLOYEE (Include Your Object iv e Findings, Sy mpt oms, and Pat ient Complaint s) DEFINE A ND GIV E THE NUM BER OF A DDITIONA L TREA TM ENTS FOR W HICH A UTHORIZA TION IS REQUESTED: Giv e t he Dat e By W hich t he Treat ment W ill Be Complet ed If A ut horizat ion is Grant ed: M UST PROV IDE NEW PRESCRIPTION W ITH EACH ADDITIONAL TREATM ENT REQUEST Dat eSignat ure and A ddress of Phy sical Therapist Telephone Number P. T. FOR INSURER' S ACTION [ ] A UTHORIZA TION IS GRA NTED FOR [ ] A ut horizat ion f or A ddit ional Phy sical Therapy A DDITIONA L P. T. TREA TM ENTS Treat ment is Denied. Treat ing Phy sician W ill Be Consult ed in t his case. [ ] Ot her A ct ion: Dat e Signat ure Tit le D-3 3 (rev . 7 / 9 9 )