Care Provider Forms & Fact Sheets 2017-05-18T10:43:58+00:00

Care Provider Forms & Fact Sheets


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Form Name Last modified
Accreditation Request – Primary level services 2006-Jun
Accreditation Request – To add assessment team member 2016-Feb-11
Accreditation Request – To add treatment team member 2016-Feb-11
Client health questionnaire 2015-Jul-31
Direct Deposit Application 2016-Jul-08
Functional examination record 2015-Jul-31
International health care provider report (CR) 2016-Oct-04
Job Information Worksheet (JIW) 2015-Dec-10
Lower extremity functional scale (LEFS) 2016-May-6
Neck disability index (NDI) 2016-Oct-04
Notification of Intake for Secondary or Tertiary Treatment Program (MCARETX) 2015-May-15
Roland Morris for backs 2015-Jul-31
QuickDASH 2015-Jul-31
Request for funding for new or replacement hearing aids (MCARE) 2015-Jun-01
Hearing Loss Questionnaire 2015-Dec-10
Therapist’s Billing Form (THER) 2004-Dec-21
Chiropractor’s Initial Report (CHI)
See also: CHI User Manual
Chiropractor’s Progress/Discharge Report (CHP)
See also: CHP User Manual
Practitioner’s Return to Work (PRTW)
See also: PRTW User Manual
Chiropractor’s Billing Form (CHRO) 2016-Aug-23
Enabling Certificate for Medical Review Panel Examination (ECMRP) 2014-Feb-28
Dentist’s Initial Report (M7) 2015-Nov-01
Doctor’s Billing Form (DOC) 2000-Apr-06
Exercise, Massage & Occupational Therapy
Occupational Therapist’s Initial Report (OTI) 2015-Jun-01
Occupational Therapist’s Progress/Discharge Report (OTP) 2015-Jun-01
Primary Authorization to Treat – Exercise, Occupational Therapy & Other 2013-Oct-01
Primary Level Authorization to Treat – Massage Therapy (MCARE) 2012-Jun-24
Practitioner’s Initial Assessment (TXI) 2015-Oct-01
Practitioner’s Progress Report (TXP) 2015-Oct-01
Practitioner’s Discharge Summary (TXD) 2015-Oct-01
Therapist’s Billing Form (THER) 2004-Dec-21
Hospital Admission/Discharge Record 2012-Aug-23
Physical Therapy
Physiotherapist’s Initial Report (PTI)
See also: PTI User Manual
Physiotherapist’s Progress/Discharge Report (PTP)
See also: PTP User Manual
Practitioner’s Return to Work Report (PRTW)
See also: PRTW User Manual
Physiotherapist’s Billing Form (PHYS) 2016-Aug-23
Physician’s Initial Report (PPI) 2016-Aug-25
Physician’s Progress/Discharge Report (PPP) 2015-Nov-01
Practitioner’s Return to Work Report (PRTW)
See also: PRTW User Manual
Doctor’s Billing Form (DOC) 2000-Apr-06
Enabling Certificate for Medical Review Panel Examination (ECMRP) 2014-Feb-28
Initial Assessment (PSYI) 2017-Jan-9
Progress/Discharge Report (PSYP) 2016-Jul-20
List of Restrictions 2016-Oct-04
Therapist’s Billing Form (THER) 2004-Dec-21


Fact Sheets & Publications


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