Page 123 - R2P Front Desk Manual v1

3. Under Forms, click Therapy Request Form. The blank form will open in a new window.

4. Fill out the form online and print it once complete, or print it out and complete it by hand.
a. # of Pages Faxed = Form (as the first page) + any notes that will be included.
b. Request for: Select Onset (Commencement) of Therapy Services for an initial
evaluation or Extension of Therapy Services for additional authorization.
c. Is this request for post-operative therapy visits? Indicate Yes or No.
d. Select Physical Therapy for Service Type.
e. Diagnosis Code: Enter the primary diagnosis code from the patient’s chart. If
there is more than one dx code, write “Additional Dx:” and list them in the margin.

Last Update: 7/10/19