{1}
{1}
{1}
THERAPY WAITLIST
Authorization ID:
Service Delivery Location:
select
HARRIS
JEFFERSON
Medicaid ID:
Member DOB:
Therapy Type:
select
Physical Therapy
Speech Therapy
Occupational Therapy
Speech & Physical Therapy
Speech and Occupational Therapy
Physical and Occupational Therapy
Speech, Physical and Occupational Therapy
Reason:
select
Have received a referral for service but are unable to receive an initial evaluation
Provider put services on hold for a member/client due to billing/authorization issues.
Other
Description:
Provider NPI:
Provider TPI:
Provider Name:
Provider Type:
select
ECI
Independent Therapist
Group Therapist
Home Health Agency
CORF/ORF
Rehabilitation Center
Other
Another Provider Available:
select
YES
NO