SARS FORM
PREVIOUS AUTHORIZATION NUMBER
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TODAY'S DATE (MM/DD/YYYY)
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Month
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Day
Year
Date
SECTION I: VETERAN INFORMATION
1. VETERAN'S LEGAL FULL NAME (First, MI, Last)
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Date of Birth
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Month
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Day
Year
Date
3. VA FACILITY
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SECTION II: ORDERING PROVIDER INFORMATION
5. REQUESTING PROVIDER'S NAME
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Name of Therapist Performing Evaluation
6. NPI #
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Speciality
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Please Select
PT
OT
Address:
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Please Select
325 W Morris Blvd. Morristown, TN 37813
2250 Broadway Drive Bean Station, TN 37708
410 N Broad Street New Tazewell, TN 37825
1009 Hampshire Drive Maryville, TN 37801
113 Hedrick Drive Newport, TN 37821
900 W Main Street Rogersville, TN 37857
263 E Broadway Blvd. Jefferson City, TN 37760
14. DIAGNOSIS (ICD-10 Code/Description)
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15. DATE OF SERVICE (MM/DD/YYYY) &/OR ANTICIPATED LENGTH OF CARE
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Month
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Day
Year
Date
15. DATE OF SERVICE (MM/DD/YYYY) &/OR ANTICIPATED LENGTH OF CARE
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Month
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Day
Year
Date
17. HOW MANY VISITS HAVE OCCURRED SO FAR? (If known)
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Specialty
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PT
OT
Additional Office Visits
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Check Here if You Are Requesting More
ADDITIONAL OFFICE VISITS (List # needed)
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36. JUSTIFICATION FOR REQUEST To avoid delays in care, include appropriate documentation such as office notes, current treatment plans, clinical history, laboratory results, radiology results &/or medications to support the medical necessity of services requested
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56. REQUESTING PROVIDER SIGNATURE (Required)
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