Copyright  OrthoNet LLC Instructions
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Copyright OrthoNet LLC Instructions

Use this form as a Fax Cover Sheet and send all supporting clinical data with this request 2 Please ensure that this form is a DIRECT COPY from the MASTER 3 Please PRINT in black ink one character per box for ALL requested information and completely

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Copyright OrthoNet LLC Instructions




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Copyright 2009 OrthoNet, LLC Instructions: 1. Use this form as a Fax Cover Sheet and send all supporting clinical data with this request. 2. Please ensure that this form is a DIRECT COPY from the MASTER. 3. Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle that represents the corresponding NUMBER entry where applicable. 4. For assistance in completing this form, please call OrthoNet provider services toll free at 1-888-788-0807. For Internal Office Use Only THERAPY PROVIDER INFORMATION Street Address Facility or

Provider Name City State ZIP Please fax to OrthoNet at: 1-888-788-0809 Fax Date: ____________# of Pages Faxed: _______ ANTHEM Provider ID Number The above fax number will be used to confirm your address/location if we are unable to contact you using the fax number on file with Anthem. National Provider Identifier (NPI) Individual NPI Number Facility NPI Number Month Day Year ANTHEM Therapy Fax Request Form PLEASE USE THIS FORM FOR ALL NH & CT ANTHEM MEMBERS Last Name First Name Date of Birth ANTHEM Member ID Number PATIENT INFORMATION Management Service: Utilization Management Consultative

Management Initial Evaluation Date Month Day Year Diagnosis Code (i.e. 8430 or V4365) REQUEST INFORMATION Service Type: Physical Therapy Occupational Therapy Splint Request for: Therapy Visits Precertification Other Procedure: ________________________ Is this request for post-operative therapy visits? Yes No Telephone Number FAX Number 43733 43733