Clinical Treatment Form PDF Details

The American Specialty Health (ASH) Clinical Treatment Form serves as a critical tool in the healthcare process, particularly for patients requiring physical or occupational therapy for orthopedic or neurological conditions, as well as those needing homecare or pediatric services. Located in San Diego, California, ASH outlines a systematic approach for healthcare providers to document and request approval for new or continuing care. The form, which is meticulously designed to capture a comprehensive snapshot of the patient's current condition and treatment history, requires detailed information, including patient demographics, diagnosis, treatment history, and detailed plans for continued care. Providers must also include specifics such as the date of initial visit, total number of visits to date, and anticipated future visits within a specified time frame. Furthermore, the form asks for outcome assessments critical in measuring the patient's progress and response to treatment. This level of detail ensures a holistic understanding of the patient's needs, paving the way for tailored treatment plans that enhance recovery prospects. Designed for ease of communication between providers and ASH, the form also includes sections for additional comments, enabling practitioners to supply further information to support the proposed care plan. Additionally, it is geared towards facilitating a streamlined approval process, helping to ensure timely access to necessary healthcare services.

QuestionAnswer
Form NameClinical Treatment Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesservice planning form, occupational therapy clinical visit template form, clinical treatment form pdf, ash forms for physical therapy

Form Preview Example

American Specialty Health (ASH)

CLINICAL TREATMENT FORM

P.O. Box 509001, San Diego, CA 92150-9001

PTOT-New or Continuing Care for ORTHOPEDIC conditions

Fax: 877.248.2746

For questions, please call ASH at 800.972.4226

FOR ASH

USE ONLY

ASH TREATMENT FORM #

RECEIVED DATE

ASH CLINICAL SERVICES MANAGER

Patient Name

 

 

 

 

 

 

 

 

 

 

 

 

Sex: M / F Birthdate

 

 

Patient ID#

 

 

 

 

 

 

 

 

Last

 

first

 

 

 

 

Initial

 

 

(mm/dd/yyyy)

 

 

Work Related

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscriber Name

 

 

 

 

 

 

 

 

Subscriber ID#

 

 

 

Is This? Auto Related

 

 

 

 

 

 

 

 

 

Primary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Plan

 

 

 

 

Secondary

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group #

 

 

REFERRED BY (if required) Physician Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral DX

 

 

FOR OUT-OF-NETWORK PROVIDER ONLY: TIN #

 

 

 

 

 

 

 

 

 

 

 

 

State License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI Number Type 1 (Individual)

 

 

 

 

 

 

 

 

 

 

 

 

NPI Number Type 2 (Organization)

 

 

TREATING PRACTITIONER INFORMATION

 

 

 

 

 

 

 

 

 

PATIENT MAILING ADDRESS AND PHONE NUMBER

 

Provider Group Name (clinic)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treating Therapist

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (

 

)

 

 

 

 

 

Phone (

 

 

)

 

 

 

Fax (

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICES ALREADY RENDERED

(Check one)

PT

 

OT

 

 

 

 

 

 

Eval/1st Visit date (mm/dd/yyyy) for this episode

 

 

 

 

 

 

 

 

 

Response to care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total number of Visits rendered for this episode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DME / Supports (Describe and Provide HCPC Codes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 / DIAGNOSES (Highest level of specificity – Primary Condition(s) and Pathology codes (If Post Surgery 1°=V57.1)

1

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

SERVICES THAT YOU ARE SUBMITTING FOR CONTINUED CARE

 

 

 

 

 

 

 

 

 

 

 

 

From (mm/dd/yyyy)

 

Through (mm/dd/yyyy)

 

 

# of Visits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated Discharge Date (Required)(mm/dd/yyyy)

 

 

 

 

Date of Findings Noted Below (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

Evaluations/Reevaluations being requested during the From and Through dates:

 

 

Evaluation 97001 / 97003

Re-evaluation 97002 / 97004

 

DME / Supports (Describe and Provide HCPC Codes)

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Onset/Exacerbation

 

Cause of Current Episode

 

 

Traumatic

Stage of Condition

Acute

Sub-acute

Nature of Condition

Initial Occurrence

Vital Signs Height

 

 

 

Weight

Chief Complaint(s)

 

 

 

 

 

Repetitive

Unknown

Post-Surgical (date/type)

Chronic

 

 

 

 

 

 

Exacerbation

 

Recurrent / Chronic

Blood Pressure

Area/Joint

Active ROM

Passive ROM

Strength

Mobility

End Feel

Pain Quality

Movement

R/L(Degrees)

R/L (Degrees)

R/L (0-5)

(0-6, 3=NL)

(Dull, Sharp, etc)

 

 

/

/

/

 

 

 

 

/

/

/

 

 

 

 

/

/

/

 

 

 

 

/

/

/

 

 

 

 

/

/

/

 

 

 

Pertinent Evaluation Findings (Please include location and intensity of findings and note any significant progress)

Pt’s Functional Limitations & Planned Interventions

Med/Soc Hx / Co-Morbidities (that may affect recovery)

 

 

 

 

 

 

 

OUTCOME ASSESSMENTS (List both Initial / Current date(s) and score(s) as applicable)

 

 

 

 

Initial

Current

 

Initial

 

 

 

Current

 

List Date Obtained (mm/dd/yyyy)

 

 

 

 

List Date Obtained (mm/dd/yyyy)

 

 

Roland-Morris score

 

 

 

 

Neck Index (NDI) score

 

 

Oswestry score

 

 

 

 

Optimal score

 

 

Perceived Improvement (%)

 

 

 

 

LEFS (LE) score

 

 

Other:

 

 

 

 

DASH (UE) score

ADD’L. COMMENTS

 

 

 

 

 

 

 

 

 

 

Signature of treating practitioner (Required)

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Practitioners are encouraged to submit additional information as necessary to support the interventions / care submitted

PTOT_CTFOrtho_120109.doc

01/01/2010

Provider Group Name e.g. xyzabc PC or

123abc Hospital

Actual Treating Clinicians Name, Address, etc.

For the condition you are currently treating:

-Enter the date of first visit, AND the -TOTAL number of visits you have already provided

Enter the Start and Thru date you are submitting for the new plan of care

Provide the initial Functional Outcome Tool score utilized and any follow up score.

Patient and Insured Demographics; name,

This form is for

gender, DOB, ID #, Health Plan

orthopedic conditions

Specific response to previous treatment

Based upon your clinical assessment, list acceptable diagnosis codes (see code sheet for commonly used therapy codes)

Total number of visits you are submitting for during the from and through dates

Document the clinically relevant information about this patient that outlines the condition and supports your plan of care. Include results of orthopedic tests and measures performed

The Clinical Treatment Form must be signed and dated by the treating clinician whose name appears above as well

 

American Specialty Health (ASH)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL TREATMENT FORM

 

P.O. Box 509001, San Diego, CA 92150-9001

 

 

 

PTOT - New or Continuing Care for NEURO/PEDS/HOMECARE conditions

 

Fax: 877.248.2746

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For questions, please call ASH at 800.972.4226

 

FOR ASH

 

 

 

 

ASH TREATMENT FORM #

 

 

 

RECEIVED DATE

 

ASH CLINICAL SERVICES MANAGER

 

USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex M / F Birthdate

 

 

Patient ID#

 

 

 

 

 

 

 

 

 

 

 

Last

 

First

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

Work Related

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscriber Name

 

 

 

 

 

 

 

 

 

 

Subscriber ID#

 

 

 

Is This? Auto Related

 

 

 

 

 

 

 

 

 

 

 

 

Primary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Plan

 

 

 

 

 

Secondary

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group #

 

 

 

 

 

 

REFERRED BY (if required) Physician Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral DX

 

 

 

 

 

 

FOR OUT-OF-NETWORK PROVIDER ONLY: TIN #

 

 

 

 

 

 

 

 

 

 

 

 

State License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI Number Type 1 (Individual)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI Number Type 2 (Organization)

 

 

 

 

 

 

TREATING PRACTITIONER INFORMATION

 

 

 

 

 

 

 

 

 

PATIENT MAILING ADDRESS AND PHONE NUMBER

 

 

Provider Group Name (clinic)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treating Therapist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (

 

)

 

 

 

 

 

 

 

 

Phone (

 

 

)

 

 

 

 

Fax (

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICES ALREADY RENDERED

(Check one)

PT

OT

 

 

 

 

 

 

 

 

 

Eval/1st Visit date (mm/dd/yyyy) for this episode

 

 

 

 

 

 

Response to care

 

 

 

 

 

 

 

 

 

Total number of Visits rendered for this episode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DME / Supports (Describe and Provide HCPC Codes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 / DIAGNOSES (Highest level of specificity – Primary Condition(s) and Pathology codes (If Post Surgery 1°=V57.1)

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICES THAT YOU ARE SUBMITTING FOR CONTINUED CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Through (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

# of Visits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated Discharge Date (Required)(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Findings Noted Below (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evaluations/Re-evaluations being requested during the From and Through dates:

 

Evaluation 97001 / 97003

 

Re-evaluation 97002 / 97004

 

 

 

 

 

 

DME / Supports (Describe and Provide HCPC Codes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Onset / Exacerbation

 

 

 

 

 

 

 

 

 

 

Chief Complaint(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of Current Episode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Traumatic

 

Congenital

 

Unknown

 

Post-Surgical (Date/Type)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stage of Condition

 

Acute

 

 

Sub-Acute

 

 

Chronic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nature of Condition

 

 

Initial Occurrence

 

Exacerbation

Recurrent / Chronic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vital Signs

Height

 

 

 

 

 

 

 

Weight

 

 

 

 

 

 

 

Blood Pressure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cognitive / Perceptual

Intact

Minimum

 

 

Moderate Impairment

 

Maximum Impairment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Communication

Verbal

 

Non-Verbal

 

 

Unable to Communicate

 

Relies on primary care giver for communication needs

 

 

 

 

 

 

 

Mobility

 

Ambulation / Gait Pattern

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hypotonic

 

 

 

 

 

 

 

 

 

 

 

 

 

Bed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location

Flaccid

Ataxic

Athetoid

Normal

Spastic

Rigid

 

 

 

Wheelchair / Assistive devices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Muscle Tone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transfers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Balance / Coordination

 

Normal

 

 

Deficits in the following:

 

 

 

 

 

 

 

 

 

Head

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Static Position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Good

 

 

Fair

 

Poor

Zero

 

 

 

 

Trunk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Good

 

 

Fair

 

Poor

Zero

 

 

 

 

U. E.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dynamic Position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L. E.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Activities of Daily Living

 

Independent

 

 

Deficits in the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Task

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CG/CS

Min assist

Mod assist

 

 

 

 

Max assist

 

 

 

 

 

Device

 

 

 

 

 

 

 

 

 

 

 

 

 

Task

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CG/CS

Min assist

Mod assist

 

 

 

 

Max assist

 

 

 

 

 

Device

 

 

 

 

 

 

 

 

 

 

 

 

Sensation

 

 

Intact

Impaired

 

 

 

Absent

Location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Edema

 

 

None

Edema in the following location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+1 minimal (<.5cm)

 

 

 

2+ mild (.5cm)

 

3+ moderate (.5-1.5cm)

 

 

 

+4 severe (>1.5cm)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Med/Soc Hx / Co-Morbidities (that may affect recovery)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OUTCOME ASSESSMENTS (List both Initial / Current date(s) and score(s) as applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current

 

 

 

 

 

 

 

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current

 

 

 

 

 

 

 

 

 

 

 

 

List Date Obtained (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List Date Obtained (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUG score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Peabody score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Berg Balance score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DASH score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEFS (LE) score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADD’L. COMMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of treating practitioner (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practitioners are encouraged to submit additional information as necessary to support the interventions / care submitted

 

 

 

 

 

PTOT_CTFNeuro_120109.doc

01/01/2010

Provider Group Name e.g. xyzabc PC or

123abc Hospital

Actual Treating Clinicians Name, Address, etc.

For the condition you are currently treating:

-Enter the date of first visit, AND the -TOTAL number of visits you have already provided

Enter the Start and Thru date you are submitting for the new plan of care

Provide the initial Functional Outcome Tool score utilized and any follow up score.

Patient and Insured Demographics; name,

This form is for

gender, DOB, ID #, Health Plan

neurological conditions

Specific response to previous treatment

Based upon your clinical assessment, list acceptable diagnosis codes (see code sheet for commonly used therapy codes)

Total number of visits you are submitting for during the from and through dates

Document the clinically relevant information about this patient that outlines the condition and supports your plan of care. Include results of orthopedic tests and measures performed

The Clinical Treatment Form must be signed and dated by the treating clinician whose name appears above as well

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Handling PDF documents online is a piece of cake with our PDF editor. Anyone can fill in clinical review report form here with no trouble. To make our tool better and easier to work with, we constantly come up with new features, with our users' suggestions in mind. Starting is simple! All you should do is stick to the next basic steps down below:

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How one can fill in ash clinical treatment form orthopedics part 1

2. After filling out the previous step, go on to the next step and complete the necessary details in these fields - Date of OnsetExacerbation, Chief Complaints, Cause of Current Episode Stage of, Traumatic Subacute, Acute Initial Occurrence, Repetitive Chronic Exacerbation, Unknown, PostSurgical datetype, Recurrent Chronic, Vital Signs Height, Weight, Blood Pressure, AreaJoint Movement, Active ROM RLDegrees, and Passive ROM RL Degrees.

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3. This third part is considered pretty straightforward, American Specialty Health ASH PO, Patient Name, Subscriber Name Health Plan, Last First Initial, Primary Secondary Employer, REFERRED BY if required Physician, Sex M F Birthdate, mmddyyyy, Subscriber ID, Patient ID, Work Related Is This Auto Related, Group, Referral DX, FOR OUTOFNETWORK PROVIDER ONLY TIN, and State License - all these empty fields must be filled out here.

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4. To go onward, this fourth step will require typing in a couple of form blanks. These include From mmddyyyy, Through mmddyyyy, of Visits, Estimated Discharge Date, Date of Findings Noted Below, Evaluation, Reevaluation, Date of Onset Exacerbation Cause, Vital Signs Height Cognitive, Traumatic, Congenital, Chief Complaints Unknown, PostSurgical DateType, Acute Initial Occurrence, and SubAcute, which are vital to continuing with this process.

The best ways to fill out ash clinical treatment form orthopedics portion 4

When it comes to Congenital and Date of Onset Exacerbation Cause, make sure that you don't make any mistakes here. These are the key ones in the page.

5. As you approach the completion of this document, you'll notice a few more requirements that need to be met. In particular, List Date Obtained mmddyyyy TUG, List Date Obtained mmddyyyy, ADDL COMMENTS, Signature of treating practitioner, Date, Practitioners are encouraged to, and PTOTCTFNeurodoc should be done.

ash clinical treatment form orthopedics writing process explained (part 5)

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