"Application for Jcm Clinical Exception for Ot/Pt/Slp Service (More Than 58 Hours of Service)" - New Mexico

Application for Jcm Clinical Exception for Ot/Pt/Slp Service (More Than 58 Hours of Service) is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

Form Details:

  • Released on December 1, 2018;
  • The latest edition currently provided by the New Mexico Department of Health;
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Download "Application for Jcm Clinical Exception for Ot/Pt/Slp Service (More Than 58 Hours of Service)" - New Mexico

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Application for JCM Clinical Exception for OT/PT/SLP Service
(More than 58 hours of service)
To be completed by requesting therapist
Individual:
Date application submitted:
Yes ☐
No ☐
*TBD ☐
DOB:
CARMP:
ISP Budget Year: _______/________/________ to: _______/_______/_________
* To Be Developed
Therapist:
Agency:
Therapist Phone #:
Therapist Fax #:
Therapist E-Mail:
Case Manager:
CM Agency:
CM Phone #:
CM Fax #:
CM E-Mail:
Service Type Requested:
☐ OT/OTA
☐ PT/PTA
☐ SLP
Current Budget Units Approved and Additional Clinical Exception Units Requested
Additional Unit
Current
Additional Unit
Totals
Current
Approved
Request for
Approved
Request for
Budget for
Clinical Exception
Budget for
Clinical Exception
OT/PT/SLP
OT/PT/SLP
OTA/PTA
OTA/PTA
*Standard Rate
*Incentive Rate
* Note: Replace with Clinical Rate and Integrated Rate if still on 2007 Standards.
Therapist History:
I have been providing therapy for this individual for:
< 1 year_____
1 to 2 years _____
3 to 4 years _____
5 years or more _____
*Justification for Request (Required):
Explain why more than 58 hours of service are needed to implement the attached Therapy
Intervention Plan.
Justification for Request:
Therapist’s Signature:
Application for JCM Clinical Exception for OT/PT/SLP Service
(More than 58 hours of service)
To be completed by requesting therapist
Individual:
Date application submitted:
Yes ☐
No ☐
*TBD ☐
DOB:
CARMP:
ISP Budget Year: _______/________/________ to: _______/_______/_________
* To Be Developed
Therapist:
Agency:
Therapist Phone #:
Therapist Fax #:
Therapist E-Mail:
Case Manager:
CM Agency:
CM Phone #:
CM Fax #:
CM E-Mail:
Service Type Requested:
☐ OT/OTA
☐ PT/PTA
☐ SLP
Current Budget Units Approved and Additional Clinical Exception Units Requested
Additional Unit
Current
Additional Unit
Totals
Current
Approved
Request for
Approved
Request for
Budget for
Clinical Exception
Budget for
Clinical Exception
OT/PT/SLP
OT/PT/SLP
OTA/PTA
OTA/PTA
*Standard Rate
*Incentive Rate
* Note: Replace with Clinical Rate and Integrated Rate if still on 2007 Standards.
Therapist History:
I have been providing therapy for this individual for:
< 1 year_____
1 to 2 years _____
3 to 4 years _____
5 years or more _____
*Justification for Request (Required):
Explain why more than 58 hours of service are needed to implement the attached Therapy
Intervention Plan.
Justification for Request:
Therapist’s Signature:
Application for JCM Clinical Exception for OT/PT/SLP Service
Required Information must be attached or the request will NOT be considered
(Please initial each item below to indicate that they are attached):
______ Therapy Intervention Plan (part of the Therapy Documentation Form)
______ Current Therapy Initial Evaluation or Therapy Annual Re-evaluation Report
FOR CLINICAL REVIEWER ONLY
☐Approved
☐ Partially Approved
☐ Denied
Reviewer Comments:
Reviewer’s Signature:
Date of Review:
JCM Clinical Exception Application Distribution:
 Mail, SCOMM, or Fax this form with signature or digital signature AND required documentation to:
Clinical Services Bureau, Attn: Felicia Vidro, Therapy Services Coordinator
5301 Central Ave NE, Suite 1700, Albuquerque, NM 87108
Fax: 505-841-2987
 Mail, SCOMM, or Fax a copy of this form to the applicable CSB Therapy Consultant
 Mail, SCOMM, or Fax a copy of this form to the Case Manager
CONTACT INFORMATION:
Felicia Vidro, Therapy Svcs. Coord.
Felicia.Vidro@state.nm.us
MaryBeth Schubauer, PT Consultant
MaryBeth.Schubauer@state.nm.us
Julie Mehrl, OT Consultant
Julie.Mehrl@state.nm.us
Demarre Sanchez, SLP Consultant
Demarre.Sanchez@state.nm.us
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