Department of Labor and Industries Provider Hotline 1-800-848-0811 To: From: Provider Hotline Staff OCCUPATIONAL OR PHYSICAL THERAPY TREATMENT AUTHORIZATION FAX REQUEST Fax #: (360) 902 - 6490 Therapy Clinic Business Name Contact name at Therapist’s office Phone # at Therapist’s office Fax # at Therapist’s office Injured Worker Name/Claim # WORKER NAME WORKER CLAIM # Prescribing Doctor Name (PLEASE PRINT FULL NAME OF DOCTOR) Area(s) of body being treated: Requests for services beyond 24 visits per claim must be sent to Qualis Health Number of treatment visits to date (in your clinic/practice) AUTHORIZATION REQUESTED FOR: Occupational Therapy OR Physical Therapy (Provider – complete/read statements 1-3 below, and sign on the signature line, #4.) 1. Requested # of visits: For dates (mm/dd/yyyy) 2. Anticipated frequency: times per week 3. By signing below, I certify the following statements to be true: • • • • • through The worker has shown progress during therapy treatment. The prescribing doctor has recommended continuing therapy treatment, and documentation has or is being sent to L&I. An initial evaluation report has been prepared and has or is being sent to L&I. Progress reports required by L&I have or are being sent to L&I. Treatment being provided is considered to be for the effects of the industrial injury. 4. Therapy Provider’s Signature Department response requested via (select only one) FAX PHONE DEPARTMENT RESPONSE SECTION Claim has ________paid visits on file as of____________ The treatment requested is authorized. The treatment requested is denied. Utilization review (UR) required. Provider must contact Qualis Health (1-800-541-2894 phone). ______________visits are authorized. To go beyond the 24th visit, contact Qualis Health for UR. The treatment requested has been referred to the claim manager. Explanation: Dept. Action by: Name of L&I staff member F248-055-000 Occupational Physical Therapy treatment authorization fax request 7-2008 Date and Time RESET INDEX - MED American LegalNet, Inc. www.FormsWorkflow.com Occupational OR Physical Therapy Treatment Authorization Fax Request Instructions for Completion (Form F248-055-000) This form is to be filled out by the therapy provider/clinic that is requesting authorization for continued Occupational (OT) or Physical Therapy (PT) services. Each discipline must submit a separate request. Use this form only to request authorization for outpatient OT or PT services for State Fund claims. To request authorization for: • • • • Work hardening – contact the claim manager directly Equipment and supplies – call the Provider Hotline at 1-800-848-0811 Self-insured carriers – contact the carrier directly Licensed massage practitioners – use form F248-357-000 All fields at the top of the form must be legibly and fully completed. Electronic completion: Pressing the reset button will clear all fields. The reset button will not show up when the form is printed. The form must not be e-mailed to the department. Authorization requests using this form must be done by fax. Number of treatment visits to date: Indicate the total number of treatments provided by your facility for this claim. REMINDER: Visit counts are the total number of visits per claim. New referrals, restart of therapy following surgery, or treatment of new conditions on the same claim DO NOT start again at visit 1. Occupational and Physical therapy visits accumulate separately. Section 1: Indicate the number of visits you are requesting and the time frame needed for the visits. For example, request 12 visits beginning on July 1, 2007 through July 31, 2007. Requests for services beyond 24 visits must be sent to Qualis Health (1-800-541-2894). Section 2: Indicate how many visits per week you anticipate providing. Section 4: The primary therapist or the therapist’s designated representative must sign the form to verify that the statements in section 3 are true. Preferred response: Indicate whether you wish to receive a response from the Provider Hotline staff by fax or by phone. Sending claim records and prescriptions: Print this request and fax it to 360-902-6490 with evaluations, progress reports and prescriptions. Daily notes and other records should be faxed to claim correspondence fax numbers: 360-902-4292 360-902-5230 360-902-4565 360-902-6100 360-902-4566 360-902-6252 360-902-4567 360-902-6460 Mailing records is not preferred. If mailing, the address for claim correspondence is: Department of Labor and Industries PO Box 44291 Olympia, WA 98504-4291. If you have questions about your request, contact the Provider Hotline at 1-800-848-0811. If you have additional questions about completing the form, contact the Therapy Services Coordinator at (360) 902-4480. F248-055-000 Occupational Physical Therapy treatment authorization fax request 7-2008 INDEX - MED American LegalNet, Inc. www.FormsWorkflow.com