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Physical Therapy Authorization Request
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2023-02-19T17:14:12-05:00
COSM Physical Therapy Authorization Request Form
Please Use This Form To Submit Physical Therapy Authorization Requests.
Please allow 7 Business Days for Processing.
If You Need Records Expedited, Please Call Our Office at
201-500-9450
.
Patient Name
*
First
Patient Date Of Birth
*
MM slash DD slash YYYY
Requestor Name
*
First
Requestor Company
*
Requester Phone
*
Requestor Fax
*
Requestor Email
*
Requested Codes To Authorize
*
PLEASE UPLOAD YOUR PATIENT TREATMENT NOTES YOUR REQUEST WILL NOT BE PROCESSED. WE NEED THESE TO SUBMIT THE AUTHORIZATION
*
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 10 MB.
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