Effective Date: 




Updated 5/2017



The counselor sends this form to a physician or surgeon who has examined the consumer and is recommending surgery or other medical treatment. The physician completes the form, including recommended procedures, facility to be used, anticipated length of stay, physicians involved, and other information that will help the counselor and medical services coordinator to plan services. The local medical consultant must review this form and the consumer’s case file before any planned surgery or other medical treatment.


Copies and Distribution

No copies are required. The completed form is placed in the consumer’s paper file. If the consumer’s case is sent to the state medical director for guidance and/or a decision about services, a copy of the form is included in the courtesy file.



The completed form is part of the consumer’s paper file and is retained until the end of the fiscal year the consumer’s file is closed, plus five years.


Acronyms and Definitions

CPT—Current Procedural Terminology


Special Instructions

This form is referenced in RPM Chapter 5: Services, 5.3.1 Physical Restoration Services Procedures.

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