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Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Form
F245-059-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Form
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)



Form
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.



Form
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV

Used by the clinical provider to request preauthorization for payment of additional sessions.



Form
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V

Used by the clinical provider to get preauthorization for payment of additional sessions.



Form
F800-084-000
 
Crime Victims Compensation Program Termination Report: Form VI

Used by the clinical provider to inform L&I that you are no longer conducting treatment to the client. This must be submitted within 60 days of the client's last session and you are no longer conducting treatment.



Form
F800-085-000
 





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