Form Cms-701 - Updated Plan Of Progress For Outpatient Rehabilitation

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
UPDATED PLAN OF PROGRESS FOR OUTPATIENT REHABILITATION
(Complete for Interim to Discharge Claims. Photocopy of CMS-700 or 701 is required.)
1. PATIENT’S LAST NAME
FIRST NAME
M.I.
2. PROVIDER NO.
3. HICN
4. PROVIDER NAME
5. MEDICAL RECORD NO.
6. ONSET DATE
7. SOC. DATE
(Optional)
8. TYPE
9. PRIMARY DIAGNOSIS
10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.
(Pertinent Medical D.X.)
PT
OT
SLP
CR
12. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)
RT
PS
SN
SW
13. CURRENT PLAN UPDATE, FUNCTIONAL GOALS (Specify changes to goals and plan.)
GOALS (Short Term)
PLAN
OUTCOME (Long Term)
I HAVE REVIEWED THIS PLAN OF TREATMENT AND
14. RECERTIFICATION
RECERTIFY A CONTINUING NEED FOR SERVICES.
N/A
DC
FROM
THROUGH
N/A
15. PHYSICIAN’S SIGNATURE
16. DATE
17. ON FILE (Print/type physician’s name)
18. REASON(S) FOR CONTINUING TREATMENT THIS BILLING PERIOD (Clarify goals and necessity for continued skilled care.)
19. SIGNATURE (or name of professional, including prof. designation) 20. DATE
21.
CONTINUE SERVICES OR
DC SERVICES
22. FUNCTIONAL LEVEL (At end of billing period — Relate your documentation to functional outcomes and list problems still present.)
22. SERVICE DATES
FROM
THROUGH
Form CMS-701(11-91)

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