Physical therapists treating Nevada workers' compensation patients use Form D-33 to request therapy beyond the visits already authorized. The request identifies the treating physician, the date of last treatment and number of treatments so far, describes the present condition with objective findings, symptoms and complaints, and defines the additional treatments sought and when they will be complete. A new prescription must accompany each request.
The physical therapist completes the request above 'For Insurer's Action' and signs with address and telephone, and the treating physician supplies the new prescription. The insurer completes the bottom box to grant, deny or take other action.
Download the current version from the source each time; forms change without notice.
Authorization Request for Additional Physical Therapy Treatment
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Yes. The form states that a new prescription must be provided with each additional treatment request. The physical therapist names the treating physician on the form and attaches that physician's current prescription for the further therapy being requested.
The insurer completes the 'For Insurer's Action' box at the bottom, checking that authorization is granted for additional physical therapy treatments, that it is denied, or other action, with the date, signature and title of the person deciding. A denial notes that the treating physician will be consulted.
The present condition of the injured employee, including objective findings, symptoms and patient complaints, plus a definition and number of the additional treatments requested and the date by which treatment will be completed if authorized. The date of last treatment and number of treatments since the first visit are also required.