Free F248-357-000 massage practitioner (LMP) treatment authorization fax request - Washington

Department of Labor and Industries Provider Hotline Staff FAX (360) 902-6490

MASSAGE PRACTITIONER (LMP) TREATMENT AUTHORIZATION FAX REQUEST

To: From:

Review the instructions on page 2 before you complete this form Fax #: Provider Hot Line Staff (360) 902 - 6490
Massage Clinic Business Name Phone # at LMP office Contact name at LMP office Fax # at LMP office
WORKER NAME WORKER CLAIM #

Injured Worker Name/Claim # Prescribing Doctor Name
(PLEASE PRINT FULL NAME OF DOCTOR)

Area(s) of body being treated:

Number of treatment visits to date (in your clinic/practice) AUTHORIZATION REQUESTED FOR MASSAGE TREATMENT (Massage Practitioner ­ complete/read statements 1 and 2 below, and sign on the signature line, #3.) 1. Maximum of treatments beginning on (dates) through 2. By signing below, I certify the following statements to be true:
· · · ·
·

The worker has shown progress during massage treatment. The prescribing doctor 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. Provider's Signature Department response requested via FAX PHONE DEPARTMENT RESPONSE SECTION
The massage treatment requested has been authorized. The massage treatment requested has been referred to the claim manager The massage treatment requested is denied.

RESET

Explanation:

Dept. Action by:
Name of department staff member Date and Time

F248-357-000 Massage practitioner treatment authorization fax request 05-2007

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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) requesting authorization for continued massage treatment. Use this form only to request authorization for outpatient massage treatment. 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 legibly 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. The form must not be e-mailed to the department. 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, 2007 through July 31, 2007. 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 prescriptions. Daily notes and other records should be faxed to claim correspondence fax numbers: 360-902-4292 360-902-5230 360-902-4565 360-902-6100 360-902-4566 360-902-6252 360-902-4567 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 additional questions about completing the form, contact the Therapy Services Coordinator at (360) 902-4480.

F248-357-000 Massage practitioner treatment authorization fax request 05-2007

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