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It also requires notification for any date-of-service change.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"When should an expedited request be made?",{"text":67,"@type":63},"Request an expedited review if the standard determination time could seriously jeopardize the member’s life and/or health or the member’s ability to regain maximum function.",{"name":69,"@type":60,"acceptedAnswer":70},"Where do I send the completed form and which fax number should I use?",{"text":71,"@type":63},"Fax the completed form to the appropriate fax number listed at the bottom of the form. Fax lines are provided by state/region, including specific Medicare and dual-coverage lines.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288181,1790267285,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":26,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},1099514068035,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Want faster service? Use our Provider [Portal at](Portal at provider.wellcare.com)[ provider.wellcare.com](Portal at provider.wellcare.com). \nSkilled Therapy Authorization Request Form \n*Indicates a required field \nRequirements: Clinical information and supporting documentation should consist of current physician orders, notes, and recent diagnostics. Notification is required for any date-of-service change. \nExpedited Requests: If the standard time to make a determination could seriously jeopardize the life and/or health of the member or the member's ability to regain maximum function, please call 1-855-538-0454. \n Please fax completed form to appropriate number at bottom of form. \n\n| Requestor Name* : | Fax* : | Phone* : |\n| --- | --- | --- |\n\n\n| Member Information (please print) | | | |\n| --- | --- | --- | --- |\n| Wellcare ID* : | Medicaid/Medicare ID: | | |\n| Last Name* : | First Name, MI* : | Date of Birth* :/ / | |\n| Requesting Provider (please print) | | | |\n| Wellcare ID: | NPI/Tax ID* : | | |\n| Provider Name* : | Fax* : | Phone: | |\n| Address: | City: | State: | ZIP Code: |\n| Servicing Provider or Facility (please print) | | | |\n| Wellcare ID: | NPI/Tax ID* : | | |\n| Provider/Facility Name* : | Fax* : | Phone: | |\n| Address: | City: | State: | ZIP Code: |\n| Treating Provider (please print) | | | |\n| Wellcare ID: | NPI/Tax ID* : | | |\n| Provider/Facility Name* : | Fax* : | Phone: | |\n| Address: | City: | State: | ZIP Code: |\n\n(continued) \n©Wellcare 2026 5715965_NA6PCARFRME \nInternal Approved 02032026 \n\n| Requested Services (please choose only one) | | | | | | | | | | | | |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| □ Physical Therapy | □ Occupational Therapy | | | | □ Speech Therapy | | | | □ Massage Therapy | | | |\n| □ Equine Therapy | □ Aquatic Therapy | | | | □ Other (please specify) | | | | : | | | |\n| **PT and OT service may be delegated to NIA. Please check the QRG** | | | | | | | | | | | | |\n| Place of Service: (check one): | | □ Office (11) □ Home (12) □ SNF (31) □ Hospital (22)\u003Cbr>□ Other (please specify): | | | | | | | | | | |\n| Date of last therapy\u003Cbr>evaluation or reevaluation: | | PT: | / | / | | OT: | / | / | | ST: | / | / |\n| Attach a copy of the therapy evaluation/reevaluation or progress summary (acute) for each therapy discipline requested. | | | | | | | | | | | | |\n| Diagnosis Codes* | | | | | | | | | | | | |\n| ICD-10: | | ICD-10: | | | | ICD-10: | | | | ICD-10: | | |\n| Procedure Code(s)* | | | Description | | | | | Frequency | | | | |\n| CPT Code: | | | | | | | | days a week for weeks = visits | | | | |\n| CPT Code: | | | | | | | | days a week for weeks = visits | | | | |\n| CPT Code: | | | | | | | | days a week for weeks = visits | | | | |\n| CPT Code: | | | | | | | | days a week for weeks = visits | | | | |\n| CPT Code: | | | | | | | | days a week for weeks = visits | | | | |\n| CPT Code: | | | | | | | | days a week for weeks = visits | | | | |\n\n Please fax completed form to: \n\n| Medicare Fax Lines | |\n| --- | --- |\n| Connecticut: 1-866-455-6529 | Kentucky: 1-888-361-5684 |\n| Florida Medicare only: 1-877-892-8216 | New Jersey: 1-877-892-8221 |\n| Georgia Medicare only: 1-877-892-8213 | New York: 1-877-892-8214 |\n| Florida/Georgia Dual: 1-877-277-1820 | Texas: 1-877-894-2034 |\n| Illinois: 1-877-899-2044 | All others: 1-888-361-5684 |\n\n[wellcare.com](wellcare.com)","cbCaiaHt9UggreQE","https://ap.wps.com/l/cbCaiaHt9UggreQE","pdf",98918,"English","# Skilled Therapy Authorization Request Form\n## Requirements and supporting documentation\n## Expedited requests\n## Requestor, member and provider information\n## Requested services and place of service\n## Diagnosis and procedure codes\n## Fax numbers by state/region","[{\"question\":\"What information and documents are required to submit the Skilled Therapy authorization request?\",\"answer\":\"The form requires clinical information and supporting documentation, including current physician orders, notes, and recent diagnostics. It also requires notification for any date-of-service change.\"},{\"question\":\"When should an expedited request be made?\",\"answer\":\"Request an expedited review if the standard determination time could seriously jeopardize the member’s life and/or health or the member’s ability to regain maximum function.\"},{\"question\":\"Where do I send the completed form and which fax number should I use?\",\"answer\":\"Fax the completed form to the appropriate fax number listed at the bottom of the form. Fax lines are provided by state/region, including specific Medicare and dual-coverage lines.\"}]","Skilled Therapy Authorization Request Form - Required Clinical Information - Fax Instructions | PDF",1789633207]