The American Specialty Health (ASH) Clinical Treatment Form is the standard document for requesting physical therapy, occupational therapy, and neurological treatment approvals. Healthcare providers across the US submit this form to ASH to document patient care and obtain authorization for continuing treatment.
The Clinical Treatment Form captures detailed information in four sections. Complete patient demographics, including subscriber ID and health plan name. The diagnosis section requires ICD codes and chief complaints. The treatment section records visit counts, dates, active range of motion measurements, and vital signs. The final section collects outcome assessment scores and the estimated discharge date.
Physical therapists, occupational therapists, and chiropractors use this form for ASH network patients. It applies to orthopedic cases, neurological conditions, and post-surgical rehabilitation. Related forms include the Physical Therapy Intake Form and the Occupational Therapy Referral Checklist.
Complete all required fields before submission. Include the date of initial visit, total visits to date, and projected future visits. Attach outcome assessments such as the TUG test date if applicable. Out-of-network providers must include their Tax Identification Number (TIN) and state license. For related documentation, review the Refusal of Medical Treatment Form and the Aetna Medical Benefits Request Form.
| Question | Answer |
|---|---|
| Form Name | Clinical Treatment Form |
| Form Length | 4 pages |
| Issued By | American Specialty Health (ASH) |
| Purpose | Physical, Occupational, and Neurological Therapy Authorization |
| Who Submits | Physical Therapists, Occupational Therapists, Chiropractors |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | service planning form, occupational therapy clinical visit template form, clinical treatment form pdf, ash forms for physical therapy |