Therapy providers use this form to get DEEOIC prior authorization for a rehabilitative therapy plan, such as physical, occupational or speech therapy, for an energy employee's accepted condition. It handles initial requests, re-authorizations for the same level of care, amendments for a different level, and corrections. Each service line sets units per visit, frequency and duration, which multiply into the total units requested.
The rendering therapy provider completes Parts A to E. The treating physician's role appears in Part E, where a letter of medical necessity and evidence of a face-to-face exam must accompany the therapy evaluation.
Download the current version from the source each time; forms change without notice.
Rehabilitative Therapies Authorization Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Part E requires the therapy evaluation, a letter of medical necessity, evidence of a face-to-face exam, and any medical documentation linking the need for therapy to the accepted condition. For home-based therapy, the letter must say whether the claimant is homebound. Missing documents can delay the request or lead to denial.
Re-authorization asks for the same level of care as the previous approval. Amendment asks for a different level of care, such as more visits. Correction fixes erroneous data on an existing authorization, and Initial Request is for a new or first-time therapy plan.