PT, OT & Speech Therapy - Client Discovery Form

Client Discovery Form

Physical Therapy, Occupational Therapy & Speech Therapy Providers

Purpose: This form collects provider, practice, services, location, documentation, payer, supervision, compliance, billing, and enrollment details needed to assess Medicare/Medicare Advantage, Medicaid, Medicaid MCO, commercial payer, workers compensation, school/community, and specialty therapy network requirements for PT, OT, and speech therapy providers.

Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Instructions: Complete every applicable field. Select only services currently provided or planned. Upload supporting documents through the secure upload fields/portal only. Do not email protected or sensitive documents. Use Additional Notes for payer-specific issues, specialty therapy carve-outs, or enrollment barriers.

1. Primary Client Contact & Organization Information

Organization Type / Practice Setting

2. Key Identifiers

State(s) of Licensure *

3. Ownership, Management & Administrative Structure

Add each owner separately.

4. Scope of Work

Requested Credentialing / Enrollment Services *
Target Payer Categories *
State(s) for Enrollment *

5. Key Project Information

Project Type

6. Provider Type / Credentials

Therapy Provider Type

7. Therapy Services Offered

A. Physical Therapy Services

B. Occupational Therapy Services

C. Speech Therapy / Speech-Language Pathology Services

D. Specialty Programs / Ancillary Services

8. Patient Populations Served

Check all populations served

9. Locations & Service Delivery Information

States Where Telehealth Is Provided

Common Place of Service Codes Used

10. Provider Billing & Coding Information

Common PT / OT CPT Codes Used

Common Speech Therapy CPT Codes Used

Common Therapy Modifiers / Billing Considerations

11. Provider Enrollment Roster

Complete one record per PT, OT, SLP, assistant, supervisor, or related therapy provider requiring payer enrollment or credentialing.

12. Existing Provider Enrollment

13. Supervision, Collaborative Providers & Staff

14. Compliance Protocols

15. Additional Notes / Special Considerations

16. Upload Supporting Documents

Documents containing protected or sensitive information must be uploaded only through the approved secure process.

Provider-Level Documents

Entity / Practice Documents

17. Client Acknowledgements, Signatures & Certification

Privacy, Confidentiality, and Security of Credentialing Documents

To maintain compliance with HIPAA and safeguard client privacy, confidentiality, and data security, TriumpHealth requires credentialing documents to be uploaded through the approved secure portal only.

Credentialing, Site, and Payer Requirements

The client acknowledges that payer participation may depend on provider licensure, service location, place of service, billing structure, supervision rules, payer site requirements, and clinical documentation standards.

Completion and Reimbursement Disclaimer

This Discovery Form is used to determine credentialing, enrollment, contracting, billing setup review, and compliance requirements. Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Scope of Work Precedence

In the event of any conflict, inconsistency, or discrepancy between the Scope of Work in the executed Service Agreement and project-scope information provided in the Client Intake Form, the executed Service Agreement controls.

I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge. I authorize use of this information for payer enrollment, credentialing and compliance assessment.
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