Page 112 - R2P Front Desk Manual v1
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3. From the Choose Your State dropdown menu, select Maryland and hit Go.
4. Under the blue Commercial heading, click View Offered Plan Information.
5. Click Mid-Atlantic Health Plan - UnitedHealthcare M.D.IPA Plan to expand the
section.
6. Scroll down to the Forms, Tools & Resources subheading and select Rehabilitation
Services Extension Request Form. The blank form will open in a new window.
7. Print the form for the Clinic Coordinator and treating therapist to complete ALL fields.
a. Clinic Coordinator will complete as much of the top portion of the form as able.
b. Treating PT will complete any remaining items in the top section and the entire
bottom section of the form.
8. Scan and save the completed form to the patient’s eDocs as MDIPA Auth Request
(date of form).
9. Fax the completed form with clinical notes to MDIPA:
Last Update: 7/10/19
