TNNJ Patient Intake Form

The Therapy Network of New Jersey* (TNNJ) has updated the Patient Intake Form. A copy of the new form is available on the TNNJ website, under Provider Resources, or on the Forms page of the Amerigroup Community Care website, under Prior Authorizations.

Effective September 1, 2023, the updated form will be required when requesting authorization for outpatient speech, physical, and occupational therapy services.

Why is this change necessary?

The form includes new attestation fields for the member’s plan of care required for authorization decisions.

What does this mean to me?

The plan of care frequency, duration, and intensity are necessary to be accepted for authorization approval. When completing the attestation and certifying the plan of care, please be sure the intake form matches the patient’s individual plan of care medical record. The intake form must be completed in its entirety; incomplete intake forms will be returned.

If you have any questions, please contact TNNJ at 855-825-7818 or visit their website at mytnnj.com. You may also contact your local Provider Relationship Management representative or call Provider Services at 800-454-3730 (Medicaid) or 866-805-4589 (Medicare Advantage).