Initial Visit Form

Initial Visit Form

(C) 2024 Soteria Healthcare Network, Inc. | Office Tel (770) 455-8190 ext 135
Please complete/submit this form. If answers are not complete and/or accurate, this form may be returned without authorization. This form is required if the Patient's condition requires care beyond one visit. Please note, please be as detailed/accurate as possible. If not, additional information may be required upon request. Copies of this form and more are at SoteriaHealthcare.com/downloads.

Got questions, please call 770-455-8190 ext 135 or fax # 404-341-9804

SECTION 1. TREATING DOCTOR INFORMATION.
Today's Date*

MonthDayYear
Date
Treating Doctor (First, Last)*
FIRST AND LAST NAME (REQUIRED)
Office Tel.*
Office Fax Number*
Office Email*
example@example.com

SECTION 3. TREATMENT INFORMATION.
LINE 1. Has the Doctor treated this Patient within the past 12 mos. (for any condition)*

YesNo
LINE 2. ALL DIAGNOSES (Past 12 Mos) Please list all diagnoses for which you have treated this Patient in the past 12-months. See example (below). *
IMPORTANT: Diagnoses must match the ICD-10 Code (Above) -- For example, Low Back Pain; M54.50; 10 treatments; 09/01/2023 to 10/3/2023; or, Sciatica left side; M54.32; 12 treatments; 02/08/2023 to 03/28/2023
LINE 2. ICD-10 Code(s) (Past 12 Mos) *
IMPORTANT: Diagnoses must match the ICD-10 Code (Above) -- For example, Low Back Pain; M54.50; 10 treatments; 09/01/2023 to 10/3/2023; or, Sciatica left side; M54.32; 12 treatments; 02/08/2023 to 03/28/2023
LINE 2. #er of Treatments (Past 12 Mos) *
IMPORTANT: Diagnoses must match the ICD-10 Code (Above) -- For example, Low Back Pain; M54.50; 10 treatments; 09/01/2023 to 10/3/2023; or, Sciatica left side; M54.32; 12 treatments; 02/08/2023 to 03/28/2023
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Line 3. Date when current condition began?*

MonthDayYear
Date
Line 3 (Con't) Date of first visit for current course of treatment?*

MonthDayYear
Date
LINE 4. Current Diagnoses Description AND ICD-10 CODES -- See examples (Below)*
Please list the "Current Diagnoses" and "ICD-10 Code(s)" together. See example above. For example ... Cervicalgia; M54.2 Subluxation of Lumbar Region; M99.13
LINE 4. ICD-10 Code(s) -- See examples (Below)*
Please list the "Current Diagnoses" and "ICD-10 Code(s)" together. See example above. For example ... Cervicalgia; M54.2 Subluxation of Lumbar Region; M99.13
LINE 5. Etiology or cause of current condition*
Line 6. CURRENT SUBJECTIVE COMPLAINTS. (At least one is required)
A.*
B.
C.
D.
LINE 7. Positive Orthopedic test(s) which confirm you diagnosis: (At least one is required)
A.*
B.
C.
D.

SECTION 4. VISIT ESTIMATE TO COMPLETE ACUTE PHASE OF TREATMENT.
LINE 1. "Treating Doctor estimates at total of ____ # of visits over _____ days or ____ weeks."
#er of Visits*
#er of Days; Or ...
#er of Weeks*
LINE 2. Prognosis
On a scale of 1 to 10 what is Patients pain level?*
LINE 3. Additional Treating Doctor Comments (Optional)
Treating Doctor's Signature*

Clear
Date*

MonthDayYear
Date
INSTRUCTIONS: Once signed and submitted, this document will be electronically sent via JOTFORM to Soteria Healthcare Network's Utilization Management (UM) Department for review. If you have any questions, please call Soteria Healthcare Network's U.M. Office directly at tel. (770) 455-8190 ext 135.
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