Outpatient Rehab Questionnaire

Presented To:

OP Rehab ProvidersMay 2015

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

Outpatient Rehab Questionnaire

• When initiating the questionnaire, the first question is “Are you requesting an evaluation?” if the answer is “yes”, the question “Is there a physician's order signed and dated by the physician for the evaluation?”

• Question #2: “Are you requesting outpatient rehab visits?” Answering “yes” to this question will cause a drop down menu to appear.

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

Outpatient Rehab Questionnaire

• All questions require completion for successful submission

• If you have any questions or concerns regarding completion of the questionnaires, please contact KEPRO at 1-888-827-2884

Outpatient Rehab Questionnaire

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