MEDICAL NECESSITY REVIEW FORM PT OT AT-New or Continuing Care for ORTHOPEDIC conditions For questions, please call ASH at 800.972.4226

Athletic trainers will use the Orthopedic form when treating and reporting on a sports-related injury or condition. Forms are available for practitioners to submit objective findings or any pertinent clinical information to support interventions/care needed.

American Specialty Health (ASH) P.O. Box 509001, San Diego, CA 92150-9001

Please clarify which treatment/services you are submitting for Reopen and provide rationale. You may attach the current MNR Form and additional information may also be attached or included below.

Information on the state and federal forms required for an abortion, sterilization, or hysterectomy of Medicaid beneficiaries are located on the TennCare Miscellaneous Forms website. Abortion, Sterilization, Hysterectomy (ASH) Forms Can’t find what you need? Contact [email protected].

This form is for orthopedic conditions American Specialty Health (ASH) P.O. Box 509001, San Diego, CA 92150-9001 PTOT - New or Continuing Care for NEURO/PEDS/HOMECARE conditions Fax: 877.248.2746 For questions, please call ASH at 800.972.4226

If you need to submit this form to ASH Networks, please send it to ASH Networks at the address above. If you have any questions, call ASH Networks Provider Services at 800.972.4226.

Contracted providers, health plans, and fitness centers can conduct business online with us through ASHLink.com. Visit Provider Resources or Fitness Center Resources to access materials such as: "I like using ASHLink. It makes my life much easier to check on patient eligibility and submitting claims."

The document is a Medical Necessity Review Form from American Specialty Health (ASH) designed for the submission of requests related to physical therapy (PT), occupational therapy (OT), and athletic training (AT) services for orthopedic conditions.

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