er emb mm/dd/yyyy - Quality Healthcare | eviCore forms/pt.ot hand conditions.pdf · 1. Date of - Onset: Evaluation: Current findings: Member requires treatment for a new condition

First Name: Middle Initial: Last Name:

DOB (mm/dd/yyyy ): Gender: Male Female

Street Address: Apt #:

City: State: Zip:

Cell Phone: Primary Contact: Home Cell

Health Plan: Member ID: Group ID:

First Name: Last Name:

Primary Specialty: TIN: NPI:

Physician Phone: Physician Fax:

Address: Suite #:

City: State: Zip:

Office Contact: Ext:

Contact Email:

First Name: Last Name:

Group/Site Name:

Primary Specialty: TIN: NPI:

Site Phone: Site Fax:

Address: Suite #:

City: State: Zip:

Diagnosis, if known or rule out:

ICD-10 Codes: PT OT

Auth/Reference Number (if continued care):

Date of last visit: Start date of this request:

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PT/OT Treatment Request Clinical Worksheet Hand

Conditions

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CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient (s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that anydisclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you havereceived this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without savingthem in any manner.

For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. If there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to provide all relevant information may delay the determination. Phone

request. authorization an submit to site the on located portal provider the into log also may You section. Forms Fax and Guidelines the under eviCore.com on found be can numbers fax and

URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE .

eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924 eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924

1. Date of - Onset: Evaluation: Current findings:

Member requires treatment for a new condition

Additional care for same condition treated in the last 60 days

3. What was the previous condition treated?

Elbow/Wrist/Forearm Lumbar-Pelvis Shoulder/Arm Hand

Cervical-Thoracic Hip/Thigh Knee/Thigh Ankle/Foot/Leg

4. What is the status of the previous treatment? Condition resolved Ongoing

5. Fabricating a splint/orthotic or developing a home exercise program only? Yes No

*If yes , remaining fields do not need to be completed.

6. Are any comorbidities present?

Overweight >100 lbs Diabetes CVA

Rheumatoid arthritis Multiple Sclerosis None

7. Is the treatment post-surgical? Yes No Unknown

8. What was the date of surgery? N/A

9. What was the type of surgery? N/A

10. What are the post-operative restrictions? N/A

Passive movement ONLY Active assisted allowed

Active movement ONLY No restrictions

11. Is range of motion (ROM) within normal limits? Yes No N/A

If no, what is the ROM?

12. This is for: Total active motion Individual joint motion

13. What is the side to be treated? Bilateral Left Right

Flex: MCP R: L: PIP R: L: DIP R: L: TAM R: L:

Ext: MCP R: L: PIP R: L: DIP R: L: TAM R: L:





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2. Select any of the following which apply:

Member not treated in the last 60 days

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If member requires treatment for a new condition, answer questions 3 and 4.

Thumb

Index Finger

Middle Finger






14. Indicate the strength of the hand referenced: Right Left Unknown

Power grip R: L:

Lateral pinch R: L:

R: L:

15. What is the level of pain? /10 Unknown

16. What is the frequency of pain?

0-25% 26-50% 51-75% 76-100% Unknown

17. Are there positive neural signs? Yes No Unknown

18. Do trigger points cause local or referred pain? Yes No Unknown

19. Is there an osteochondral defect? Yes No Unknown

20. Is there thumb or wrist instability? Yes No Unknown

/100 N/A

Activity 1: Level: /10



Page 3 of 3

3-jaw grip

Patient Specific Functional Scale: Score 3 activities that the patient has the most difficulty performing. 0 is unableto perform, 10 is no difficulty.

21. If DASH (Disabilities of the Arm, Shoulder, and Hand) or Quick DASHwas performed, what was the score?

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Ring Finger

Small Finger

For a second treatment request, submit an additional form and fax both forms together. Additionalinformation/comments:


Documents

er emb mm/dd/yyyy - Quality Healthcare | eviCore forms/pt.ot hand conditions.pdf · 1. Date of - Onset: Evaluation: Current findings: Member requires treatment for a new condition