"Patient Summary Form - Optum Physical Health"

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Instructions
Patient Summary Form
Please complete this form within the specified timeframe.
All PSF submissions should be completed online at
PSF-750 (Rev: 7/1/2015)
www.myoptumhealthphysicalhealth.com unless other-
Patient Information
wise instructed.
Female
Please review the Plan Summary for more information.
Male
Patient name
Last
First
MI
Patient date of birth
City
State
Zip code
Patient address
Patient insurance ID#
Health plan
Group number
Referring physician (if applicable)
Date referral issued (if applicable)
Referral number (if applicable)
Provider Information
1. Name of the billing provider or facility
2. Federal tax ID(TIN) of entity in box #1
(as it will appear on the claim form)
ATC
MT
Other
DC
OT
Both PT
OT
Home Care
MD/DO
PT
and
1
2
3
4
5
6
7
8
9
3. Name and credentials of the individual performing the service(s)
4. Alternate name (if any) of entity in box #1
6. Phone number
5. NPI of entity in box #1
8. City
7. Address of the billing provider or facility indicated in box #1
9. State
10. Zip code
Provider Completes This Section:
Diagnosis (ICD codes)
Date of Surgery
Please ensure all digits are
Date you want THIS
entered accurately
{
submission to begin:
Cause of Current Episode
1
Traumatic
4
Post-surgical
Type of Surgery
2
Unspecified
5
Work related
1
ACL Reconstruction
Patient Type
3
Repetitive
6
Motor vehicle
2
Rotator Cuff/Labral Repair
1
3
Tendon Repair
New to your office
2
4
Est’d, new injury
Spinal Fusion
3
5
Joint Replacement
Est’d, new episode
Other
4
6
Est’d, continuing care
DC ONLY
Nature of Condition
Current Functional Measure Score
Anticipated CMT Level
1
Initial onset (within last 3 months)
Neck Index
DASH
98940
98942
2
Recurrent (multiple episodes of < 3 months)
(other FOM)
98941
98943
Chronic (continuous duration > 3 months)
Back Index
LEFS
3
Patient Completes This Section:
Indicate where you have pain or other symptoms:
Symptoms began on:
(Please fill in selections completely)
1. Briefly describe your symptoms:
2. How did your symptoms start?
3. Average pain intensity:
Last 24 hours:
no pain
0
1
2
3
4
5
6
7
8
9
10
worst pain
Past week:
no pain
0
1
2
3
4
5
6
7
8
9
10
worst pain
4. How often do you experience your symptoms?
1
Constantly (76%-100% of the time)
2
Frequently (51%-75% of the time)
Occasionally (26% - 50% of the time)
3
4
Intermittently (0%-25% of the time)
5. How much have your symptoms interfered with your usual daily activities?
(including both work outside the home and housework)
1 Not at all
2 A little bit
3
4 Quite a bit
5
Extremely
Moderately
6. How is your condition changing, since care began at this facility?
6
N/A — This is the initial visit
1
Much worse
2
Worse
3
A little worse
4
No change
5
A little better
Better
7
Much better
0
7. In general, would you say your overall health right now is...
1
Excellent
2
Very good
3
Good
4 Fair
5 Poor
Patient Signature: X
Date:
Instructions
Patient Summary Form
Please complete this form within the specified timeframe.
All PSF submissions should be completed online at
PSF-750 (Rev: 7/1/2015)
www.myoptumhealthphysicalhealth.com unless other-
Patient Information
wise instructed.
Female
Please review the Plan Summary for more information.
Male
Patient name
Last
First
MI
Patient date of birth
City
State
Zip code
Patient address
Patient insurance ID#
Health plan
Group number
Referring physician (if applicable)
Date referral issued (if applicable)
Referral number (if applicable)
Provider Information
1. Name of the billing provider or facility
2. Federal tax ID(TIN) of entity in box #1
(as it will appear on the claim form)
ATC
MT
Other
DC
OT
Both PT
OT
Home Care
MD/DO
PT
and
1
2
3
4
5
6
7
8
9
3. Name and credentials of the individual performing the service(s)
4. Alternate name (if any) of entity in box #1
6. Phone number
5. NPI of entity in box #1
8. City
7. Address of the billing provider or facility indicated in box #1
9. State
10. Zip code
Provider Completes This Section:
Diagnosis (ICD codes)
Date of Surgery
Please ensure all digits are
Date you want THIS
entered accurately
{
submission to begin:
Cause of Current Episode
1
Traumatic
4
Post-surgical
Type of Surgery
2
Unspecified
5
Work related
1
ACL Reconstruction
Patient Type
3
Repetitive
6
Motor vehicle
2
Rotator Cuff/Labral Repair
1
3
Tendon Repair
New to your office
2
4
Est’d, new injury
Spinal Fusion
3
5
Joint Replacement
Est’d, new episode
Other
4
6
Est’d, continuing care
DC ONLY
Nature of Condition
Current Functional Measure Score
Anticipated CMT Level
1
Initial onset (within last 3 months)
Neck Index
DASH
98940
98942
2
Recurrent (multiple episodes of < 3 months)
(other FOM)
98941
98943
Chronic (continuous duration > 3 months)
Back Index
LEFS
3
Patient Completes This Section:
Indicate where you have pain or other symptoms:
Symptoms began on:
(Please fill in selections completely)
1. Briefly describe your symptoms:
2. How did your symptoms start?
3. Average pain intensity:
Last 24 hours:
no pain
0
1
2
3
4
5
6
7
8
9
10
worst pain
Past week:
no pain
0
1
2
3
4
5
6
7
8
9
10
worst pain
4. How often do you experience your symptoms?
1
Constantly (76%-100% of the time)
2
Frequently (51%-75% of the time)
Occasionally (26% - 50% of the time)
3
4
Intermittently (0%-25% of the time)
5. How much have your symptoms interfered with your usual daily activities?
(including both work outside the home and housework)
1 Not at all
2 A little bit
3
4 Quite a bit
5
Extremely
Moderately
6. How is your condition changing, since care began at this facility?
6
N/A — This is the initial visit
1
Much worse
2
Worse
3
A little worse
4
No change
5
A little better
Better
7
Much better
0
7. In general, would you say your overall health right now is...
1
Excellent
2
Very good
3
Good
4 Fair
5 Poor
Patient Signature: X
Date: