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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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