SECTION 4 - FORMS

? PT/OT Intake .............................................................................................................................1? Outcomes ...................................................................................................................................2? PT/OT Treatment (TX) Form ....................................................................................................3? Advanced Review Form (need description)...............................................................................4? Claim Grievance Form...............................................................................................................5? UM Appeal & Grievance Form .................................................................................................6

FORMS

PT/OT Intake FormVersion 1.2 (July 20, 2009) www.palladianhealth.com/members

Insurance plan

Member ID

First name

Date Date of birth

1. Why are you here today? If there are many reasons, please check only the most important problem. Neck Mid-back Lower back Headache

Shoulder Elbow Wrist Hand

Hip Knee Ankle Foot

Cardiac Stroke Spinal cord Post-surgery

Wound care/burns Balance/coordination Pelvis/incontinence Other injury/illness

2. When did this problem first begin?Check Box

<1 week ago 1-6 weeks ago 7-12 weeks ago 3-12 months ago >12 months ago

Please answer each of the following questions with a "yes" or "no". No Yes3 Is this problem related to a work injury?4 Is this problem related to a motor vehicle accident?5 Have you ever had this problem in the past?6 Have you ever had diagnostic testing such as x-rays or MRI for this problem?7 Does this problem generally get worse with movement or activity?8 Does this problem generally get better with rest?

Please answer each of the following questions with a "yes" or "no". No Yes9 Do you currently feel weakness in both your arms that makes lifting them difficult?10 Do you currently feel weakness in both your legs that makes walking difficult?11 Do you currently have any numbness in your groin area, genitals, or buttocks?12 Have you recently noticed a lot of problems with your balance (falling or knocking into things)?13 Have you recently had difficulty controlling your bowel movements?14 Have you recently had difficulty controlling your urine or been unable to urinate?15 Have you recently had a lot of difficulty remembering where you are?16 Have you recently had a lot of visual problems such as blurred or double vision?17 Have you recently felt dizzy, faint, or light-headed a lot?18 Have you recently felt a lot of pain in your chest?19 Have you recently felt a lot of shortness of breath?20 Have you recently noticed that your heart is beating a lot more rapidly than normal?21 Have you recently been coughing up a lot of blood?22 Do you currently have a weakened immune system?23 Have you ever used any injected drugs (non-prescription)?24 Do you currently have a severe fever or chills?25 Have you recently been sweating a lot more than usual?26 Have you recently had any type of infection?27 Have you recently had any type of surgery or surgical procedure?28 Are currently taking any blood thinner medication (Coumadin, heparin, daily aspirin)?29 Have you recently felt that one leg was a lot warmer than the other?30 Have you recently noticed a lot of swelling or severe skin color changes in one or both legs?31 Have you ever been diagnosed with osteoporosis (weak, soft, or brittle bones)?32 Have you ever used steroids such as prednisone for more than 4 weeks?33 Have you recently had any other any other type of accident (falling from a height)?34 Have you ever been diagnosed with cancer?35 Have you recently lost a lot of weight without trying to?If you answered "yes" to any of the questions in the section immediately above (numbers 9-35):No Yes36 Were you recently given the OK by a medical doctor to receive physical or occupational therapy?

Last name

Outcomes FormVersion 1.1 (July 15, 2009) www.palladianhealth.com/members

For each of the following 12 questions, please mark an "X" in the one box that best describes youranswer.

1 In general, would you say your health is Excellent Very good Good Fair Poor

The following questions are about activities you might do during a typical day.Does your health now limit you in these activities? If so, how much?

Yes,limiteda lot

Yes,limiteda little

No, notlimitedat all

2 Moderate activities, such as moving a table, pushinga vacuum cleaner, bowling, or playing golf

3 Climbing several flights of stairsDuring the past week, how much of the time have you had any of the following problems with your work or other regulardaily activities as a result of your physical health?

All ofthe time

Most ofthe time

Some ofthe time

A little ofthe time

None ofthe time

4 Accomplished less than you would like5 Were limited in the kind of work or other activitiesDuring the past week, how much of the time have you had any of the following problems with your work or other regulardaily activities as a result of any emotional problems (such as feeling depressed or anxious)?

All ofthe time

Most ofthe time

Some ofthe time

A little ofthe time

None ofthe time

6 Accomplished less than you would like7 Did work or other activities less carefully than usual8 During the past week, how much did pain interfere

with your normal work (including both work outsidethe home and housework)?

Not at all A little bit Moderately Quite a bit Extremely

These questions are about how you feel and how things have been with you during the past week.For each question, please give the one answer that comes closest to the way you have been feeling.How much of the time during the past week... All of

the timeMost ofthe time

Some ofthe time

A little ofthe time

None ofthe time

9 Have you felt calm and peaceful?10 Did you have a lot of energy?11 Have you felt downhearted and depressed?12 During the past week, how much of the time has your

physical health or emotional problems interfered withyour social activities (like visiting friends, relatives,etc.)?

All ofthe time

Most ofthe time

Some ofthe time

A little ofthe time

None ofthe time

Please mark an "X" in the one box that best describes the severity of your main problem for each timepoint:Time point 0 1 2 3 4 5 6 7 8 9 10

13 Right now Not severe Worst possible14 On average Not severe Worst possible15 At its best Not severe Worst possible16 At its worst Not severe Worst possible

Last name

Insurance plan

Member ID

First name

Date Date of birth

PT/OT Treatment FormVersion 1.3 (August 4, 2009)

www.palladianhealth.com/providers

Section A. Provider informationSpecialty Physical therapy Occupational therapyFirst name Tax ID - -Last name NPI - -Phone Fax - -Practice nameAddress

Number Street City State ZipSection B. Patient information

First name Gender Female MaleLast name Date of birth

M M D D Y Y Y YSection C. Insurance information

Check if Worker's compensationCheck if No-fault insurance

Section D. Referring physician information (if applicable)Date of examination

Date of prescription

Section E. Date informationDate of injury/illness/surgery Date of last visitDate of first visit Requested visit start

Section F. Primary region of complaint (select onlyone)Spine Upper extremity Lower extremity Rehabilitation Other

Cervical Shoulder L R Hip L R Cardiac Wound care/burnsC/S+radiculopathy Elbow L R Knee L R Stroke Balance/coordinationThoracic Wrist L R Ankle L R Spinal cord Pelvis/incontinenceLumbosacral Hand L R Foot L R Post-surgical Other illness/injuryL/S+radiculopathy Developmental Cancer

Diagnosis for primary region of complaint (i.e. ICD-9 code or approved corresponding text description):

Section G. Red flagsDoes this patient have any red flags indicative of potentially serious pathology? No YesIf yes, is this a contraindication to receiving PT/OT care from you for this complaint? No Yes Not applicable

Section H. EvaluationBased on information provided by the patient, your examination, and your treatment history with this patient (if any),what is your evaluation of this patient's primary region of complaint? Please check one box for each of these columns.Symptoms Function Co-morbidities Prognosis

Very mild Very good None Very goodMild Good Very few GoodModerate Moderate Few ModerateSevere Poor Many PoorVery severe Very poor Very many Very poor

Section I. Treatment Supervised exercise Education Home exercise Modalities Manual therapy Other

Number of PT/OT visits for primary region of complaint since last PT/OT Treatment Form was submitted

Provider signature DateCompleting and signing this form indicates that the provider:1. provided/supervised all PT/OT services, and 2. is a participating PT/OT provider, and 3. provided all PT/OT services in a credentialed practice.

First nameLast name

Health Plan

Member ID

StevenBraverman212-594-6054Steven L. Braverman, PT PC450 Seventh Avenue, New York, NY 10123

PT/OT Advanced Treatment FormVersion 1.2 (July 30, 2009) www.palladianhealth.com/providers

Provider signature DateCompleting and signing this form indicates that the provider:1. provided/supervised all PT/OT services, and 2. is a participating PT/OT provider, and 3. provided all PT/OT services in a credentialed practice.

Section A. Provider informationFirst name NPILast name Telephone

Section B. Patient informationFirst name Member IDLast name

Date of birthSection C. Advanced evaluation

Please indicate the specific symptoms, functional limitations, co-morbidities, and prognostic indicators on which youbased your evaluation of these factors in this patient on the PT/OT Treatment Form. Please check all that apply.Symptoms Functionallimitations Co-morbidities Prognosticindicators

BurningCoughingFatigueLocal painLoss of balanceLoss of coordinationLoss of hearingLoss of speechLoss of visionNumbnessParalysisPoor cognitionPoor concentrationPoor memoryRadicular painReferred painRigidityShortness of breathSpasmSpasticityStiffnessTenderness to touchTinglingVertigo/dizzinessVisible deformityWeaknessOther

General:BathingBreathingCarryingChewingDressingDrivingFeedingGroomingKneelingLiftingPullingPushingRunningSittingSleepingStandingSwallowingVoidingWalkingRegion of complaint:CoordinationEnduranceRange of motionStrength

Other

AmputationAnalgesic dependencyAnxietyAuto-immune diseaseBleeding disorderCancerCardiopulmonary diseaseChemotherapyCognitive deficiencyCongenital anomalyDegenerative arthritisDepressionDiabetesEmotional disturbanceHearing impairmentInflammatory arthritisLocal infectionObesityPhysical deformityPoly-pharmacyPoor dietPoor physical fitnessRecent surgerySmokingSpeech impairmentSystemic infectionOther

Advanced ageAdvanced stage conditionDifficulty communicatingMaximum medicalimprovement reachedNot receiving requiredmedical/surgical treatmentPoor attendancePoor compliancePoor general healthPrior failed PT/OT treatmentsRe-injurySecondary gainTreatment effects short-termOther

Please indicate if there is any other region of complaint in addition to the primary region of complaint in this patient.Please check all that apply.Spine Upper extremity Lower extremity Rehabilitation Other

Cervical Shoulder L R Hip L R Cardiac Wound care/burnsC/S+radiculopathy Elbow L R Knee L R Stroke Balance/coordinationThoracic Wrist L R Ankle L R Spinal cord Pelvis/incontinenceLumbosacral Hand L R Foot L R Post-surgical Other illness/injuryL/S+radiculopathy Developmental Cancer

1255308375

212-594-6054StevenBraverman

CLAIMS GRIEVANCE FORM

Requests must be received by Palladian Health within 90 days of the date on the EOB. To expedite your request,please include any and all information, documentation, EOB's needed to review your request.Requests may be submitted to:

Palladian Health: Attention Claims Dept. 2732 Transit Rd. West Seneca, NY 14224 -or- Fax: (716) 712-2790

Practitioners Last Name First Name ID Number

Address City State Zip Code

Telephone Number Fax Number

**************** GRIEVANCE SUMMARY ****************(Please Print)

Member's Last Name First Name Health Plan

Member Health Plan ID Date of Service

APPEAL & GRIEVANCE REQUEST FORM

Requests may be submitted via fax (716) 712-2798 or via postal service to Palladian Health Attention: Grievance &Appeals Dept. 2732 Transit Rd. West Seneca, NY 14224

Appeal Grievance

Practitioners Last Name First Name ID Number

Address City State Zip Code

Telephone Number Fax Number

Name of Person Filing Appeal

Member's Last Name First Name Health Plan ID Number

Date of Occurrence Date of Filing Authorization Number

************** APPEAL or GRIEVANCE SUMMARY **************(Please Print)