Rehabilitation Forms

Request for continued therapy beyond initial authorization period. Must document progress toward goals and continued medical necessity.

Written plan outlining the vocational goal, services needed, service providers, and timeline. Must be agreed upon by the client and VR counselor.

Pre-certification for inpatient rehab admission. Must document patient can participate in 3 hours of therapy, 5 days per week (15 hours per week).

Assessment instrument determining Medicare Part A FFS payment for IRF stays. Must be in the patient's medical record, dated, timed, and authenticated.

Prior authorization for outpatient physical therapy, occupational therapy, or speech therapy. Must specify frequency, duration, and medical necessity.

Submitted to maintain IPPS-excluded status for inpatient rehabilitation facilities.

Documents that a rehabilitation unit is fully equipped and staffed for hospital inpatient rehabilitation care.

Application for VR services to help people with disabilities prepare for, find, and keep jobs. Eligibility based on disability that creates a barrier to employment.