Thsteps-CCP PCS Assessment Prior Authorization Request Form And

Request for Extension of Outpatient Therapy

(2 Pages) (Form TP-2)

Request for Extension of Outpatient Therapy (Form TP-2)
CCP - Texas Medicaid Healthcare Partnership
PO Box 200735
Austin TX 78720-0735
1-800-846-7470
CCP FAX: 1-512-514-4212 / Texas Medicaid Healthcare Partnership
CSHCN
PO Box 200855
Austin TX 78720-0855
1-800-568-2413 or 1-512-514-3000
FAX: 1-512-514-4222
Medicaid Number: / CSHCN Number:
Client Name: / Date of birth: / / Telephone:
Client Address:
Has the child received therapy in the last year from the public school system? □ Yes □ No
Date of Initial Evaluation / PT / OT / SLP
A copy of the initial evaluation must be attached
ICD-9 Code/Diagnosis: / Date of onset:
Category of Therapy Being Requested
PT/OT for: / X□ Developmental anomalies / □ Pre-surgery / □ Post-surgery Date of surgery / /
□ Cast Removal Date Removed / / □ Serial Casting / □ Acute Episode of Chronic Condition
□ New Condition / □ Specialty Clinic / x□ Home Program / x□ ADL (activities of daily living)
□ Equipment Assessment / □ Equipment Training
Speech for: / □ Craniofacial / □ Developmental Anomalies / □ New Condition / □ Post Cochlear Implant
Check the service requested, indicate the date(s) of service and frequency per week or month:
Dates of service cannot exceed six months. If possible, end requested date of service on the last day of the month.
Service Type / Service Date(s) / Frequency per week / Frequency per month
From: / To:
□ PT / / / / /
□ OT / / / / /
□ SLP / / / / /
Procedure code(s) for therapy services: 97004; 97110; 97112;97530 Modifier: GO
Specialist / Name / Signature / Date Signed
Physician / / /
PT Therapist / / /
OT Therapist / Gibson Gelladuga,OT / / /
SLP Therapist / / /
Provider Information
Name: TTS PEDIATRICS / Telephone: 713-344-1214 / Fax: 1-888-336-7050
Address: 7545 HIGHMEADOWS DRIVE HOUSTON, TX 77063
Medicaid Identifying Information
TPI: 208527601 / NPI: 1740517044 / Taxonomy: 225X00000X / Benefit Code: CCP
CSHCN Identifying Information
TPI: / NPI: / Taxonomy: / Benefit Code:
FOR OFFICE USE ONLY: Medicaid □ Yes □ No HMO □ Yes □ No Restrictions:
FORM TP-2 Page 1 of 2

Effective Date_07302007/Revised Date_06012007

PAN# Valid To

Medicaid Number: / CSHCN Number:
Client Name: / Date of birth: / /
Current Functional Status:
New Treatment Goals:
Prior Dates of Service: from / to / /
Prior Functional Status:
Prior Treatment Goals:
Prior Treatment Provided:
FORM TP-2 Page 2 of 2

Effective Date_07302007/Revised Date_06012007