Get the free physical therapy referral form NEW REV fo08-09 - eastconn

Physical Therapy Department 376 Hartford Turnpike Hampton, CT 06247 Telephone (860) 455-0707 Fax (860) 455-0691 PHYSICIAN S REFERRAL FOR PHYSICAL THERAPY SERVICES Student Name: Physician: Date of

How to fill out physical therapy referral form

How to fill out a physical therapy referral form:

1. Start by gathering all the necessary information. This may include the patient's personal details such as name, address, contact number, and date of birth. Additionally, you may need to collect specific medical information such as the reason for referral, any relevant diagnoses, and any previous treatments or therapies.
2. Make sure to accurately fill out the referring physician's details. This typically includes their name, address, phone number, and any relevant identification or license numbers.
3. Clearly indicate the patient's insurance information. This may include the name of the insurance company, policy number, group number, and any necessary authorization or pre-certification requirements. If the patient does not have insurance, make note of this as well.
4. Include any relevant supporting documentation. This may involve attaching copies of medical records, test results, or previous treatment plans. These documents help provide a complete picture of the patient's condition and aid in determining the appropriate course of physical therapy.
5. Don't forget to include the patient's signature and date on the referral form. This ensures that the patient gives consent for the referral and acknowledges the information provided.

Who needs a physical therapy referral form?

1. Patients who have sustained an injury or are experiencing musculoskeletal pain that requires physical therapy may need a referral form. This includes individuals recovering from surgeries, accidents, or sports-related injuries, as well as those with chronic conditions such as arthritis or back pain.
2. Healthcare professionals, such as primary care physicians, orthopedic surgeons, neurologists, and other specialists, may require a physical therapy referral form to initiate appropriate treatment for their patients. The referral form helps ensure that the patient receives the necessary therapy to address their specific condition.
3. Insurance companies often require a physical therapy referral form to determine coverage and payment for the services rendered. By having a referral form, insurance providers can verify that physical therapy is medically necessary and meets their coverage criteria.

In conclusion, filling out a physical therapy referral form involves gathering patient information, accurately documenting physician and insurance details, attaching relevant supporting documentation, obtaining the patient's signature, and dating the form. Both patients who need physical therapy and healthcare professionals referring them may require this form to initiate treatment and secure insurance coverage.

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What is physical therapy referral form?

Physical therapy referral form is a document used to refer a patient to an authorized physical therapist for evaluation and treatment.

Who is required to file physical therapy referral form?

Healthcare providers such as doctors, physician assistants, and nurse practitioners are required to file a physical therapy referral form.

How to fill out physical therapy referral form?

You can fill out a physical therapy referral form by providing the patient's information, reason for referral, and any relevant medical history.

What is the purpose of physical therapy referral form?

The purpose of a physical therapy referral form is to ensure that patients receive appropriate physical therapy services to aid in their recovery or rehabilitation.

What information must be reported on physical therapy referral form?

The physical therapy referral form must include the patient's name, date of birth, insurance information, referring provider's signature, and details of the therapy needed.