Geisinger Health Plan has announced the launch of its new Form A health insurance plan. The new Form A plan offers comprehensive coverage and a wide range of benefits, making it an excellent choice for individuals and families. Geisinger Health Plan is committed to providing quality, affordable health care coverage, and the new Form A plan is evidence of that commitment. With this plan, members have access to some of the best health care providers in the country. Plus, there are a variety of wellness programs available to help members stay healthy. If you're looking for reliable health insurance coverage, be sure to check out the new Geisinger Health Plan Form A plan.
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 |
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____________________________________________________________________________________________
____________________________________________________________________________________________
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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: ___________________________ |
HPCHS02: Form A Sept 2008 Devised: 10/99 Revised: 3/01, 7/06, 2/08, 9/08