Therapy Authorization Form

Please use this form to submit a new referral or IPC revision.

We will not be able to hold a position for your client after 30 days of the request for IPC revision.

Once the IPC is revised, please submit a new therapy authorization form with the updated hours.

Once a recommendation is made for IPC revision, we must receive the revision within 30 days of the request for hours.

Agency Information

Case Manager's Name

Client Information

Client's Name
Client's Treatment Address

Legal Guardian Information

Legal Guardian's Name

Scheduling Contact's Information

Scheduling Contact's Name

Physician's Information

Physician's Name

Day Hab's Information

Day Hab's Address

IPC Information

Select each Discipline needed and indicate hours approved. (If this is a revision, list number of hours added.)
Select Discipline(s) Needed

Hours Needed for Initial Evaluations

ST - 3 Hours
OT - 3 Hours
PT - 3 Hours
DI - 4 Hours
BH - 4 Hours
Counseling - 4 Hours

Hours Needed for Initial Equipment/Home Modifications Evaluations

10 Hours

NOTICE….

We will not be able to hold a position for your client after 30 days of the request for IPC revision. Once the IPC is revised, please submit a new therapy authorization form with the updated hours. Once a recommendation is made for IPC revision, we must receive the revision within 30 days of the request for hours.