Attending Provider Treatment Plan
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1
2ATTENDING PROVIDER TREATMENT PLAN
INITIAL SUBMISSION
FOLLOW-UP SUBMISSION
DATE SUBMITTED
Month
Day
Year
TYPE OR PRINT LEGIBLY
CLAIM #:
PATIENT INFORMATION
POLICYHOLDER INFORMATION (if different)
1. PATIENT'S NAME
11. DATE OF ACCIDENT
14. POLICYHOLDER'S NAME
Last
First
Initial
Last
First
Initial
2. PATIENT'S ADDRESS (No. Street)
12. IS PATIENT'S CONDITION
15. POLICYHOLDER'S ADDRESS (No. Street)
RELATED TO:
3. CITY
4. STATE
A. EMPLOYMENT?
16. CITY
17. STATE
YES
NO
5. ZIP CODE
6. TELEPHONE # (Include Area Code)
B. AUTO ACCIDENT?
18. TELEPHONE # (Include Area Code)
19. ZIP CODE
NO
YES
20. RELATIONSHIP TO PATIENT
7. PATIENT BIRTHDATE
8. SEX
C. OTHER ACCIDENT?
M
F
YES
NO
9. INSURANCE COMPANY
13. IS PATIENT UNABLE TO WORK?
10. POLICY NUMBER
NO
YES
PROVIDER INFORMATION
21. NAME OF TREATING PROVIDER
22. TAX I.D.
23. NPI
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)
MEDICATIONS
MRI
SURGERY
X-RAY
DIAGNOSTIC TEST
EXISTING CONDITIONS
COMORBIDITIES
OTHER
36. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (38C)
ICD Ind.
9
10
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
37. CHECK APPROPRIATE CARE PATH (if applicable)
CP1
CP2
CP3
CP4
CP5
CP6
PROPOSED COURSE OF TREATMENT AS IT RELATES TO THIS MVA
PROCEDURES, SERVICES OR SUPPLIES
38. DATE(S) OF REQUEST
FROM
TO
(Explain Unusual Circumstances)
DIAGNOSIS
EQUIPMENT
SPINAL INJECTION
POINTER
FREQUENCY
FREQUENCY
DURATION
New
Rental
Unilateral
Bilateral
MM
DD
YY
MM
DD
YY
CPT/HCPCS
TOTAL UNITS
(Times per visit)
(Visits per week)
(# of weeks)
INCLUDE SUPPORTING DOCUMENTS
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 PREVIEWED THIS FORM. THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
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