Get the free PT Screening Referral Form - btsdus

100 John Robert Thomas Drive, Eaton, PA 19341 Phone: 6103637009 Fax: 6103637055 OCCUPATIONAL THERAPY SCREENING SECONDARY STUDENT REFERRAL FORM TO BE COMPLETED BY TEACHER: DATE: STUDENT NAME: DOB:

How to fill out pt screening referral form

How to Fill Out PT Screening Referral Form:

1. Start by writing your personal information, including your name, address, phone number, and date of birth, in the designated fields.
2. Next, provide your insurance information, such as your insurance company name, policy number, and group number. If applicable, include any secondary insurance information as well.
3. Indicate the reason for seeking physical therapy by checking the appropriate box or providing a brief description in the designated space.
4. Write the name of your primary healthcare provider or referring physician, along with their contact information, including their name, clinic or hospital name, address, phone number, and fax number.
5. If you have any relevant medical history or previous treatments related to the current condition, provide as much detail as possible in the designated section.
6. In the section for current medications, list any medications you are currently taking, including prescription drugs, over-the-counter medications, and supplements. Include the name of the medication, dosage, frequency, and the prescribing doctor's name, if applicable.
7. If you have any known allergies or adverse reactions to medications, make sure to mention them in the designated area.
8. Finally, sign and date the form at the bottom to indicate that the information provided is accurate and complete.

Who needs PT Screening Referral Form:

1. Patients who are considering or have been recommended physical therapy by their primary healthcare provider or referring physician.
2. Individuals who have specific conditions, injuries, or chronic pain that may require physical therapy as part of their treatment plan.
3. Anyone seeking to access physical therapy services through their health insurance, as many insurance companies require a referral from a healthcare professional to cover the costs.

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What is pt screening referral form?

The PT screening referral form is a document used to refer patients for physical therapy services.

Who is required to file pt screening referral form?

The referring healthcare provider or physician is required to file the PT screening referral form.

How to fill out pt screening referral form?

The PT screening referral form can be filled out by providing patient information, reason for referral, and relevant medical history.

What is the purpose of pt screening referral form?

The purpose of the PT screening referral form is to ensure patients receive appropriate physical therapy services.

What information must be reported on pt screening referral form?

Information such as patient demographics, insurance information, medical diagnosis, and referral reason must be reported on the PT screening referral form.