Evaluation Request

Date:

Dear Doctor:

Please sign the attached ìEvaluation/Plan of Careî and return it to our office in the enclosed envelope.

Some insurance guidelines required a physicianís approval for a particular plan on all patients. The prescription for Physical Therapy does not suffice. The requirements ask for problems, goals, frequency, and duration upon completion of the initial evaluation and every subsequent thirty days of treatment. We will send your office a ìPlan of Careî for your signature on all patients we are treating.

If you should have any further questions, please feel free to contact our office.

Thank you.

Sincerely,