When individuals seek outpatient rehabilitative therapy services through the Geisinger Health Plan, they encounter a key document known as Form A. This essential paperwork initiates the referral process for new cases, ensuring that members get the targeted rehabilitation they need, whether that's physical therapy (PT), occupational therapy (OT), speech therapy (ST), or other specialized services. The form requires detailed information right from the start, including member and referral source details, the specific rehabilitation provider involved, and crucial member data such as their health plan provider number and date of birth. Furthermore, it addresses the necessity of documenting other insurance details, possibly indicating workman's compensation or auto insurance, alongside a comprehensive section dedicated to diagnosing information, including ICD-9 codes and descriptions of surgical procedures. The form also delves into the patient’s functional level prior to their current issue, outlines current problems and durations, and charts out goals and a plan of care, all of which are foundational in forming a tailored, patient-centric rehabilitation program. This exhaustive documentation process, underscored by the need for thoroughness and accuracy, not only facilitates a seamless referral but also ensures that the care provided aligns with the patient's specific rehabilitation needs. The form concludes with sections for therapist and case manager signatures, which validate the planned course of treatment and authorize the number of visits, emphasizing that while approval signifies the appropriateness of care level, it does not guarantee payment.
| Question | Answer |
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| Form Name | Geisinger Health Plan Form A |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | CORF, appropriateness, 2008, Workmans |
Geisinger Health Plan Outpatient Rehabilitative Therapy Services Network |
FORM A |
OUTPATIENT REHABILITATIVE THERAPY SERVICES REFERRAL FORM |
(New Case) |
Phone: (570) |
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SECTION 1 – (to be completed and faxed upon initial visit) *Required information. Incomplete forms will be returned unprocessed.
Member Information |
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Referral Source |
*Rehab Provider Facility Name |
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*Last Name, First Name, MI: |
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Referring Physician |
Location: |
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*First Name, Last Name |
*Health Plan Provider #: |
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*DOB: |
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*Phone: ( ) |
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*Phone # |
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Address: |
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*Fax: ( |
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*Fax #: |
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Phone #: |
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*Service Requested |
*Site of Service: |
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*GHP ID#: |
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PT |
OT |
ST |
O/P Clinic |
SNF |
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Hospital |
CORF |
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Assisted Living Facility |
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OTHER INSURANCE INFORMATION: (Workman’s Compensation, Auto Insurance, etc.) |
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Company: |
Policy Number: |
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Claim Number: |
Date of Accident: |
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Contact Person: |
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Phone Number: |
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DIAGNOSIS INFORMATION |
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*DESCRIPTION: |
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SURGICAL PROCEDURES: (Include Dates) |
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Psychosocial Factors: |
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SECTION 2 –
Functional level prior to current problem: __________________________________________________________________________
__________________________________________________________________________________________________________
Current Problems/Duration: (Include specific Clinical Information) Or |
Eval attached /or 1 visit only Requested |
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Goals:
1._____________________________________________________________________________________________________
2._____________________________________________________________________________________________________
3._____________________________________________________________________________________________________
4._____________________________________________________________________________________________________
5._____________________________________________________________________________________________________
Plan of Care: ______________________________________________________________________________________________
Therapist Signature: _____________________________________ Date: _____________________________________________
For Geisinger Health Plan Outpatient Rehabilitative Services Network Only
Authorization #: |
# of Approved Visits: |
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Discipline authorized: PT |
OT |
ST |
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Approval verifies appropriateness of a level of care and is not a guarantee of payment. |
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Case Manager Signature: ____________________________________________________ |
Date: ___________________________ |
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HPCHS02: Form A Sept 2008 Devised: 10/99 Revised: 3/01, 7/06, 2/08, 9/08