Illinois Medicaid fee-for-service requires prior approval for physical, occupational and speech therapy, and HFS 3701T is the request. Therapy providers meet it when starting or renewing a course of therapy, and the referring practitioner's role shows in the attached plan of care. HFS reviews the visits per week, number of weeks and total visits requested against the evaluation or progress note sent with it.
The therapy provider completes the form, including recipient and provider details, the referring physician's name, diagnosis, procedure codes and visit schedule, and signs it. The practitioner signs and dates the therapist's plan of care that must be attached.
Download the current version from the source each time; forms change without notice.
Therapy Prior Approval Request Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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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No. The form states that the evaluation visit should not be included in the quantity of visits requested. Enter only treatment visits, expressed as visits per week and number of weeks, and do not convert them into 15-minute units, which the form says not to use.
Attach the plan of care signed by the therapist, with the practitioner's signature and date. Initial requests also include the evaluation, and renewal requests include the re-evaluation or a progress note. The separate HFS 3701TI instructions explain each numbered field on the form.