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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
*
CPT Codes To Authorize
*
97110
97140
97014
97112
97010
97164
97530
97535
97162
G0283
OTHER
OTHER CODES REQUESTED
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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