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Lymphedema Program: PT/OT Therapy Intake Form
Required for all Lymphedema requestsPlease use this fax form for MONUMENT requests only. Failure to provide all relevant information may
delay the determination.
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How to fill out EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake
01
Obtain the EviCore Healthcare Lymphedema Program intake form from the EviCore website or your healthcare provider.
02
Fill in the patient's personal information, including name, date of birth, and contact information.
03
Provide relevant medical history related to lymphedema, including previous treatments and diagnoses.
04
Document the specific site of lymphedema and the severity of the condition.
05
List any current medications and therapies the patient is undergoing.
06
Include your provider information, such as name, practice, and contact details.
07
Sign and date the form to verify that the information provided is accurate.
08
Submit the completed form to EviCore Healthcare via the specified method (online, fax, etc.).
Who needs EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake?
01
Patients diagnosed with lymphedema who require physical or occupational therapy.
02
Individuals experiencing swelling in their limbs due to surgery, radiation therapy, or other medical conditions related to lymphedema.
03
Healthcare providers looking to refer patients for specialized lymphedema management.
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What is EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake?
The EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake is a structured process for initiating physical and occupational therapy specifically for patients suffering from lymphedema. It involves collecting necessary clinical information to ensure the patient receives appropriate care.
Who is required to file EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake?
Healthcare providers, such as physical therapists, occupational therapists, and referring physicians, are required to file the EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake.
How to fill out EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake?
To fill out the intake form, providers should gather relevant patient information, including medical history, current symptoms, and previous treatments. All required fields must be completed accurately before submitting to EviCore Healthcare.
What is the purpose of EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake?
The purpose of the EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake is to assess and document the specific needs of patients with lymphedema to facilitate effective treatment planning and ensure appropriate care interventions.
What information must be reported on EviCore Healthcare Lymphedema Program: PT/OT Therapy Intake?
The information that must be reported includes patient demographics, medical history, detailed description of lymphedema symptoms, previous treatment records, assessment findings, and any additional relevant clinical information.
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