Get the free REFERRAL FORM - Concussion Care - concussion-care

P.O. Box 53060, RPO South St. Vital Winnipeg, MB R2N 3×2 Phone: 2044150784 Fax: 2042314442 REFERRAL FORM EARLY INTERVENTION PROGRAM LIVING WITH SYMPTOMS PROGRAM 1. CLIENT DETAILS Client name: DOB:

How to fill out referral form - concussion

How to fill out referral form - concussion:

1. Obtain the referral form: Contact your healthcare provider or the relevant medical institution to request the referral form for concussion evaluation.
2. Fill in personal information: Start by providing your full name, date of birth, address, and contact information at the top of the form. Ensure that this information is accurate and up to date.
3. Specify the reason for referral: In the designated section, clearly state that the referral is for a concussion evaluation. This helps healthcare professionals understand the purpose of the referral.
4. Include relevant medical history: Provide a summary of your medical history related to concussions or any other relevant neurological conditions. Include details such as previous concussions, symptoms experienced, and previous treatments received.
5. Describe the present symptoms: Clearly outline the symptoms you are currently experiencing that are indicative of a concussion. This may include headaches, dizziness, memory problems, blurred vision, or other related symptoms.
6. Indicate any related events or circumstances: If the concussion was caused by a specific incident or event, provide details about what happened, such as the date, location, and any relevant circumstances.
7. Include any additional relevant information: If there are any other factors that the healthcare provider should consider, such as previous imaging or tests, medications, or ongoing treatments for related conditions, make sure to include that information on the form.
8. Sign and date the form: Once you have completed all the necessary sections, carefully review the form to ensure accuracy and sign and date it wherever indicated.

Who needs referral form - concussion?

A referral form for a concussion evaluation is typically needed by individuals who suspect they have experienced a concussion and require further medical assessment. This may include athletes who have suffered a head injury during a sporting event, individuals involved in accidents causing head trauma, or individuals who are experiencing symptoms consistent with a concussion. The referral form is usually required by healthcare providers, such as primary care physicians or neurologists, to initiate the evaluation process and to coordinate appropriate care.

People Also Ask about

What is the CPT code for concussion clinic?

The first 30 minutes of test administration and scoring is billed using 96136 and each additional 30-minute increment needed to complete the service is billed with code 96137.

What is CPT code 96136?

For test administration and scoring for psychological/neuropsychological testing use codes 96136, 96137, 96138 and 96139. For automated testing and results for psychological/neuropsychological testing use code 96146.

When would you refer a patient with concussion?

Health care professionals should consider referral to a concussion specialist if: The symptoms worsen at any time, The symptoms have not gone away after 10-14 days, or. The patient has a history of multiple concussions or risk factors for prolonged recovery.

What is the score for the concussion test?

The measure consists of 22 questions that relate to post-concussive symptoms. Survey-takers are asked to rate each symptom ing to a 7-point likert scale ranging from 0-6. Higher scores indicate a higher severity of post-concussive symptoms. The greatest possible score is 132 and the lowest possible score is 0.

What is the code for concussion screening?

Concussion without loss of consciousness, initial encounter S06. 0X0A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

What is the care plan for a concussion?

Physical and mental rest Relative rest, which includes limiting activities that require thinking and mental concentration, is recommended for the first two days after a concussion. However, complete rest, such as lying in a dark room and avoiding all stimuli, does not help recovery and is not recommended.

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