Form Cms-700 - Plan Of Treatment For Outpatient Rehabilitation
ADVERTISEMENT
1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION
(COMPLETE FOR INITIAL CLAIMS ONLY)
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
RT
PS
SN
SW
12. PLAN OF TREATMENT FUNCTIONAL GOALS
PLAN
GOALS (Short Term)
OUTCOME (Long Term)
13. SIGNATURE (professional establishing POC including prof. designation)
14. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)
I CERTIFY THE NEED FOR THESE SERVICES FURNISHED UNDER
17. CERTIFICATION
THIS PLAN OF TREATMENT AND WHILE UNDER MY CARE
N/A
FROM
THROUGH
N/A
15. PHYSICIAN SIGNATURE
16. DATE
18. ON FILE (Print/type physician’s name)
20. INITIAL ASSESSMENT (History, medical complications, level of function
19. PRIOR HOSPITALIZATION
at start of care. Reason for referral.)
FROM
TO
N/A
21. FUNCTIONAL LEVEL (End of billing period) PROGRESS REPORT
CONTINUE SERVICES OR
DC SERVICES
22. SERVICE DATES
FROM
THROUGH
Form CMS-700-(11-91)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 700 - Certificate Of Conversion For Entities Converting Within Or Off The Records Of The Ohio Secretary Of State 2008
Legal
Form Cscl/cd-700 - Articles Of Organization For Use By Domestic Limited Liability Companies - 2014
Business
Related Categories
Parent category: Medical