F248-357-000 massage practitioner (LMP) treatment authorization by dpf99262


									 Department of Labor and Industries                             MASSAGE PRACTITIONER (LMP)
 Provider Hotline
                                                              TREATMENT AUTHORIZATION FAX

 To:               Provider Hotline Staff                    Fax #:        (360) 902 - 6490
                  Massage Clinic Business Name                            Contact name at LMP office

                  Phone # at LMP office                                   Fax # at LMP office
 Injured Worker Name/Claim #
                                                       WORKER NAME                               WORKER CLAIM #
 Referring Provider Name
                                                                     (PRINT FULL NAME)
  Area(s) of body being treated including side of body:

  Number of treatment visits to date (in your clinic/practice)

         (Massage Practitioner – complete/read statements 1 and 2 below, and sign on the signature line, #3.)
 1. Requested # of visits:                       for dates (mm/dd/yyyy)                         through
 2. By signing below, I certify the following statements to be true:
              •   The worker has shown progress during massage treatment.
              •   The referring provider has recommended continuing massage treatment,
                  and documentation has or is being sent to L&I.
              •   An initial evaluation report has been prepared and has or is being sent to L&I.
              •   Progress reports required by L&I have or are being sent to L&I.
              •   Treatment being provided is considered to be for the effects of the industrial injury.
 3. Therapy Provider’s Signature
 Department response requested via                 FAX            PHONE

 DEPARTMENT RESPONSE SECTION                                Claim has _______paid visits on file as of _________
     The treatment requested is authorized.
     The treatment requested is denied.
     The treatment requested has been referred to the claim manager for review and return call.


 Dept. Action by:
                                       Name of L&I staff member                                        Date

F248-357-000 Massage practitioner treatment authorization fax request 1 2010            RESET                 INDEX - MED
                            LMP Treatment Authorization Fax Request
                                  Instructions for Completion
                                                   (Form F248-357-000)

This form is to be filled out by the licensed massage practitioner (LMP)/clinic requesting authorization for
continued massage treatment.
Use this form only to request authorization for outpatient massage treatment for State Fund claims.
To request authorization for:
    • Equipment and supplies – call the Provider Hotline at 1-800-848-0811
    • Self-insured carriers – contact the carrier directly
    • Physical or Occupational Therapy – use form F248-055-000

All fields at the top of the form must be legible and fully completed.
Electronic completion: Pressing the reset button will clear all fields. The reset button will not show up
when the form is printed. Authorization requests using this form must be done by fax.
Number of treatment visits to date: Indicate the total number of treatments provided by your facility for
this claim.
Section 1: Indicate the number of visits you are requesting and the time frame needed for the visits. For
example, request 6 visits beginning on July 1, 2010 through July 31, 2010.
Section 3: The licensed massage practitioner’s or the LMP’s designated representative must sign the form
to verify that the statements in section 2 are true.
Preferred response: Indicate whether you wish to receive a response from the Provider Hotline staff by
fax or by phone.
Sending claim records and prescriptions:
Print this request and fax it to 360-902-6490 with evaluations, progress reports and referrals.
Daily notes and other records should be faxed to claim correspondence fax numbers:
        360-902-4292              360-902-4565              360-902-4566       360-902-4567
        360-902-5230              360-902-6100              360-902-6252       360-902-6460
Mailing records is not preferred. If mailing, the address for claim correspondence is:
        Department of Labor and Industries
        PO Box 44291
        Olympia, WA 98504-4291

If you have questions about your request, contact the Provider Hotline at 1-800-848-0811.
If you have additional questions about completing the form, contact the Therapy Services Coordinator at
(360) 902-4480.

F248-357-000 Massage practitioner treatment authorization fax request 1 2010                      INDEX - MED

To top