1. Outpatient Rehab Questionnaire Presented To: OP Rehab Providers May 2015 INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

2. 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.

3. Outpatient Rehab Questionnaire

11. 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 11