Follow Up Visit Form

Follow Up Visit Treatment Plan 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*
Office Tel.*
Office Fax Number*
Office Email*
example@example.com

SECTION 2. PATIENT AND INSURANCE INFORMATION.
Patient/Member Full Name*

Member First NamePatient/Member Last Name
Member ID#*
Patient/Member Date of Birth*

MonthDayYear
Date
Sex*
Health Plan Name
Is this Patient a dependent?*

YesNo
This case is ...*

Group HealthWorkers CompAuto Liability (Submit auto declarations page)
File Upload

Cancelof
Is Kaiser Permanente the Patients primary insurance carrier?*

YesNo

SECTION 3. TREATMENT INFORMATION.
Line 1. 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 1. Please list all ICD-10 Code(s) 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 1. Please list #er of Treatments 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 1. Please list all Start Date(s) 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 1. Please list all End Date(s) 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 2.1a Current Diagnoses -- 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 2.1b ICD-10 CODE(S) FOR Current Diagnoses -- 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 2.2a Current Diagnoses -- 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 2.2b ICD-10 CODE(S) FOR Current Diagnoses -- 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 2.3a Current Diagnoses -- 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 2.3b ICD-10 CODE(S) FOR Current Diagnoses -- 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 3. Date when current condition began? Please note: If submitting for continuing care of an acute episode, please use data collected at time of initial examination.*

MonthDayYear
Date
LINE 4. Etiology or cause of current condition*
Please state reason (Above) for request for additional visits, etiology, cause of current condition or exacerbation, if applicable.
Line 5. Has "acute phase of treatment" been completed? (Yes/No)*
Line 5. (Con't) If No, date projection of completion?*

MonthDayYear
Date
Line 6. % of recovery to date*
Line 6. (Con't) Date of first visit for current course of treatment?*

MonthDayYear
Date
Line 7. On a scale of 1-10, what was/is the patients pain level INITIALLY?*
Line 7. (Con't) On a scale of 1-10, what was/is the patients CURRENT pain level?*
Line 8. CURRENT SUBJECTIVE COMPLAINTS. (At least one is required)
A.*
B.
C.
D.
LINE 9. 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. Have you placed the Patient on specific recommendations/limitations? (Yes/No) If Yes, please describe.*
Line 2. (Con't) Please describe ...
LINE 3. Has the Patient been compliant? (Yes/No)*
Line 3. (Con't) Describe home exercise/therapy advised.
LINE 4. 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 119.
Should be Empty:

Follow Up Visit Treatment Plan Form