Therapy Attestation

1
ID Number
2
Provider Name & Practice Name
Provider First Name
Provider Last Name
My role is...
My role is...
Provider
Office Staff
Medical Assistant/Nursing Staff
Form Submitter's Role
Practice or Facility Name
3
Provider Email
example@example.com
4
Submitter Name
Your First Name
Your Last Name
5
Submitter Email
example@example.com
6
Patient Name* This field is required.
First Name
Last Name
7
Patient DOB* This field is required.Note: It may be faster to type the DOB than to try to use the date picker.
DOB
Month
Day
Year
8
Most Recent Appointment* This field is required.
Date
Month
Day
Year
9
Next Scheduled Appointment(Optional)
Date
Month
Day
Year
10
Clinical Notes (Optional)Feel free to attach clinical notes for coordination of care.
Drag and drop files here
Select files to upload
Max. file size: 50.0MB
Only .pdf, .doc, and .docx allowed. Maximum of three (3) uploads.
Cancelof
11
Other Notes for Medical Staff (Optional)
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: