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Physicians who use the Care Management Office appreciate the ease of referring their patients to therapy. The closest clinic to the patient is already figured out. The benefit information and authorization through the patient’s insurance is obtained. If we can’t reach the patient to schedule in 3 business days, the physician’s office is notified.

 

Care Management Office Form

Physician and/or Group Name

   Contact(s)
Address   Physician's Name(s)
City, State, Zip   Tax ID Number
Telephone   Special Instructions
or requests
Fax
In order for us to obtain authorization for you, we need physician provider numbers. Please submit these provider numbers by selecting the company from the list provided, filling in the corresponding provider number, then click “submit.”  Feel free to add additional providers by selecting “other,” then fill in the specific company and provider number.  Some insurance companies require authorization to be obtained through the primary care physician only. In these cases, we will work with the PCP to help obtain the authorization.
  Insurance name   If Other, please specify
  Physician   ID Number
           

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