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Initial this part of the Authorization for Release of Health Information Pursuant to HIPAA and sign form
item 9B
List the 4 forms that are presented to the ICO
Certification of LOD Injury/Authorization for Treatment (photocopy)
Authorization for Release of Health Information Pursuant to HIPAA (photocopy)
Therapy Verification
Notification of LOD Therapy Authorization
Give these forms to your therapist before treatment
Get this information from your therapy provider and forward to Roll Call
Schedule of treatments. Any change in the therapy schedule gets reported to Roll Call personnel
Update this form after each physical therapy session
Therapy Verification form. Give the completed form to the ICO once the final physical therapy treatment has been done
Physical therapy authorized by a district surgeon is never granted for this type of injury
Never granted for a non LOD injury. The fact that a member is on restricted duty does not entitle them to attend physical therapy on duty
When you have to go to physical therapy at the beginning of tour, you will report on duty upon arrival at therapy location and be given this much time to get back to the command once you're finished
You'll be given a reasonable amount of time to travel back to command
When you have to go to physical therapy in the middle of your tour, you'll be given this much time to go, do your therapy and get back
You'll be given a reasonable amount of time to get to the therapy location, complete the therapy, and a reasonable amount of time to get back to the command
When you have to go to physical therapy near the end of your tour, you'll be given this much time to get to the therapy location
You'll be given a reasonable amount of time to get to the therapy location, but once you're done with therapy you will EOT from there and no time will be granted for you to go home. If you finish therapy before EOT, you must ask for lost time by calling the command
If your therapy is scheduled after the start of tour and you'd rather go straight there from home, you must hand this in
Hand in a 28 for lost time if your physical therapy is set after the start of tour and you just want to go there from home
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