Attending Provider Treatment Plan
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1ATTENDING PROVIDER TREATMENT PLAN
INITIAL SUBMISSION
FOLLOW-UP SUBMISSION
Month
Day
Year
TYPE OR PRINT LEGIBLY
CLAIM #:
DATE SUBMITTED
PATIENT INFORMATION
POLICYHOLDER INFORMATION (if different)
1. PATIENT'S NAME
12. DATE OF ACCIDENT
15. POLICYHOLDER'S NAME
Last
First
Initial
First
Initial
Last
2. PATIENT'S ADDRESS (No., Street)
13. IS PATIENT'S CONDITION
16. POLICYHOLDER'S ADDRESS (No.; Street)
RELATED TO:
3. CITY
4. STATE
A. EMPLOYMENT
17. CITY
18. STATE
Y ES
NO
5. ZIP CODE
6.TELEPHONE # (Include Area Code)
B. AUTO ACCIDENT?
19. TELEPHONE # (Include Area Code)
20. ZIP CODE
Y ES
NO
7. PATIENT BIRTHDATE
8. SEX
9. S.S. NUMBER
C. OTHER ACCIDENT?
21. RELATIONSHIP TO PATIENT
M
F
Y ES
NO
10. INSURANCE COMPANY
14. IS PATIENT UNABLE TO WORK?
11. POLICY NUMBER
Y ES
NO
PROVIDER INFORMATION
22. NAME OF TREATING PROVIDER
23. TAX I.D. NUMBER
24. SPECIALTY
25. FACILITY OR OFFICE NAME
Last
First
Initial
26. FACILITY/OFFICE ADDRESS (No.; Street)
27. CITY
28. STATE
29. ZIP CODE
30. TELEPHONE # (Include Area Code)
31. EMAIL ADDRESS
32. FAX # (Include Area Code)
33. INITIAL DATE OF TX
34. DATE OF LAST VISIT
35. PATIENT MEDICAL HISTORY. HAS PATIENT EVER HAD ANY OF THE FOLLOWING SERVICES? CHECKMARK THOSE APPLICABLE BELOW.
(*NOTE-ALL BOXES CHECKED REQUIRE A BRIEF DESCRIPTION OF SERVICE AND DATE PROVIDED ON SEPARATE ATTACHMENT)
MRI
SURGERY
X-RAY
DIAGNOSTICS TESTING
OTHER
ALL MEDICATION
36. PRIMARY DIAGNOSIS (ICD-9)
37. SECONDARY DIAGNOSIS (ICD-9)
38. ADDITIONAL DIAGNOSIS (ICD-9)
39. ADDITIONAL DIAGNOSIS (ICD-9)
PROPOSED COURSE OF TREATMENT AS IT RELATES TO THIS MVA
40. DATE(S) OF TREATMENT REQUESTED
41. CHECK APPROPRIATE CARE PATH (If applicable)
FROM
TO
CP4
CP6
CP1
CP2
CP3
CP5
42. REQUEST FOR SERVICES : CPT / HCPS / NDC CODES
FREQUENCY
FREQUENCY
DURATION
(Use left box for single codes or left and right box for a range of codes)
(Times per visit)
(Visits per week)
TOTAL UNITS
(Number of weeks)
42. CHECKMARK ATTACHMENTS BELOW. (*NOTE-ALL SUPPORTING DOCUMENTS CHECKED MUST BE PROVIDED ON SEPARATE ATTACHMENT)
PROGRESS NOTES
SOAP NOTES
TEST RESULTS
MEDICAL HISTORY
PRESCRIPTIONS
OTHER
FRAUD PREVENTION-NEW JERSEY WARNING
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
PROVIDER STATEMENT
I HAVE PERSONALLY COMPLETED AND REVIEWED THIS FORM. THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
43.
SIGNATURE OF PROVIDER
DATE
ATPT Form Version 1.1 (9/2004)
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Parent category: Medical