Free D-33 - Nevada

AUTHORIZATION REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATMENT
PLEASE TYPE OR PRINT AND PROVIDE ALL OF THE INFORMATION REQUESTED
Claim Number

Name of Injured Employee Name of Employer Date of Last Treatment

REQUEST FOR ADDITIONAL PHYSICAL THERAPY TREATMENT
SSN# Date of Injury

Name of Treating Physician Number of Treatments Since Injured's First Visit

DESCRIBE THE PRESENT CONDITION OF THE INJURED EMPLOYEE (Include Your Objective Findings, Symptoms, and Patient Complaints)

DEFINE AND GIVE THE NUMBER OF ADDITIONAL TREATMENTS FOR WHICH AUTHORIZATION IS REQUESTED:

MUST PROVIDE NEW PRESCRIPTION WITH EACH ADDITIONAL TREATMENT REQUEST
Date Signature and Address of Physical Therapist Telephone Number

Give the Date By Which the Treatment Will Be Completed If Authorization is Granted:

P.T.
FOR INSURER'S ACTION

[ ]

AUTHORIZATION IS GRANTED FOR ADDITIONAL P.T. TREATMENTS

[ ]

[ ] Other Action:

Authorization for Additional Physical Therapy Treatment is Denied. Treating Physician Will Be Consulted in this case.

Date

Signature

Title

D-33

(rev. 7/99)