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2PRIOR AUTHORIZATION / SPELL OF ILLNESS ATTACHMENT (PA/SOIA)
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F-11039 (10/15)
SECTION III — DOCUMENTATION (Continued)
I hereby certify that the documentation of the acute onset, exacerbation, or regression of the member's disease, injury, or condition is
as stated above. I acknowledge that the SOI ends when the skilled services of a therapist are no longer required, when the plan of
care is met, or when the number of treatment sessions granted have been used, whichever comes first. I acknowledge that unused
treatment days from one SOI may not be carried over to a new SOI and that treatment days covered by Medicare or other third-party
insurance shall be included in computing the SOI treatment. I acknowledge that the provider is responsible for maintaining
documentation to justify this SOI and all recordkeeping requirements.
14. SIGNATURE — Therapist Providing Evaluation / Treatment
15. Date Signed
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