Prior Authorization / Home Health Therapy Attachment (Pa/hhta) Page 2

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PRIOR AUTHORIZATION / HOME HEALTH THERAPY ATTACHMENT (PA/HHTA)
Page 2 of 2
F-11044 (07/12)
SECTION III — DOCUMENTATION (Continued)
11. State member’s therapy history. (Indicate type / date / location for all types of therapy.)
Service Area
Location
Date
Problem Treated
Physical
Therapy
Occupational
Therapy
Speech and
Language
Pathology
12. Indicate the date of initial evaluation. (Supply dates / tests used / results of additional evaluations.)
13. Describe progress in measurable / functional terms since treatment was initiated or last authorized.
14. Attach a plan of care indicating specific, measurable goals and procedures to meet those goals.
15. Describe rehabilitation potential.
16. SIGNATURE — Requesting Provider
17. Date Signed
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