Therapist Activity Form

Please use this form to submit your patients' daily activity.

One patient/One date of service per submission

Please contact Andrea if you have questions: admin2@phawellness.com / (612) 299-1636.

 

  • Note: Insurance cos only pay for the amount of time patient is present.
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  • Previous diagnoses will auto-populate on claims. Indicate those dxs you would like to remove, &/or those you would like to add to current dxs listed for this patient.
  • Choose one
  • Card numberExp date (mo/yr)CVVS code