Attending Provider Treatment Plan (APTP) at a glance
What it is: The Attending Provider Treatment Plan, APTP Form Version 2.1 (3/2016), is an Initial Submission or a Follow-up Submission.
Who signs: Sign in Box 39 (Signature of Provider) and enter the Date.
A filled-in Attending Provider Treatment Plan (APTP) example: an initial treatment plan after an auto accident
How to fill out Attending Provider Treatment Plan (APTP), box by box
Initial or follow-up submission and date
Check Initial Submission or Follow-up Submission.
Enter the Date Submitted as Month, Day and Year.
Patient information
Type or print legibly under Patient Information and Policyholder Information (if different), and enter the Claim #.
In Box 1, enter the Patient's Name: Last, First and Initial.
Enter the Patient's Address (No. Street) in Box 2, the City in Box 3, the State in Box 4 and the Zip Code in Box 5.
Enter the Telephone # (Include Area Code) in Box 6.
Enter the Patient Birthdate in Box 7 and the Sex, M or F, in Box 8.
Enter the Insurance Company in Box 9 and the Policy Number in Box 10.
Date of accident and the patient's condition
Enter the Date of Accident in Box 11.
In Box 12, check YES or NO for Is Patient's Condition Related To: A. Employment?, B. Auto Accident? and C. Other Accident?
In Box 13, check NO or YES for Is Patient Unable To Work?
Policyholder information (if different)
If different, enter the Policyholder's Name in Box 14: Last, First and Initial.
Enter the Policyholder's Address (No. Street) in Box 15, the City in Box 16, the State in Box 17 and the Zip Code in Box 19.
Enter the Telephone # (Include Area Code) in Box 18.
Enter the Relationship to Patient in Box 20.
Provider information
Under Provider Information, enter the Name of Treating Provider in Box 21: Last, First and Initial.
Enter the Tax I.D. in Box 22, the NPI in Box 23, the Specialty in Box 24 and the Facility or Office Name in Box 25.
Enter the Facility/Office Address (No. Street) in Box 26, the City in Box 27, the State in Box 28 and the Zip Code in Box 29.
Enter the Telephone # (Include Area Code) in Box 30, the Email Address in Box 31, the Fax # (Include Area Code) in Box 32 and the Initial Date of TX in Box 33.
Enter the Date of Last Visit in Box 34.
Patient medical history
In Box 35, check the services the patient has ever had: Medications, MRI, Surgery, X-Ray, Diagnostic Test, Existing Conditions, Comorbidities or Other.
All boxes checked require a brief description of service and date provided on a separate attachment.
Diagnosis or nature of illness or injury
In Box 36, enter the Diagnosis or Nature of Illness or Injury in A to L, with the ICD Ind. 9 or 10, and relate A-L to the service line below using the Diagnosis Pointer in section 38.
Care path
In Box 37, check the appropriate Care Path (if applicable): CP1, CP2, CP3, CP4, CP5 or CP6.
Proposed course of treatment
For the Proposed Course of Treatment as it relates to this MVA, enter the Date(s) of Request in Box 38: FROM and TO, each as MM, DD and YY.
Enter the Procedures, Services or Supplies (Explain Unusual Circumstances) as the CPT/HCPCS.
For Equipment, check Purchase or Rental; for Spinal Injection, check Unilateral or Bilateral.
Enter the Diagnosis Pointer.
Enter the Frequency (Times per visit), the Frequency (Visits per week), the Duration (# of weeks) and the Total Units.
Supporting documents
Include Supporting Documents.
Common questions about Attending Provider Treatment Plan (APTP)
Who signs it?
Sign in Box 39 (Signature of Provider) and enter the Date.
Is there a penalty?
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
What am I certifying when I sign?
The provider has personally completed and previewed this form, and the information is true and correct to the best of the provider's knowledge and belief.
Sources
[1] Attending Provider Treatment Plan, APTP Form Version 2.1 (3/2016), New Jersey Department of Banking and Insurance (the Official source link on this page).
