Get the free PHYSICAL THERAPY REFERRAL FORM - flint.umich.edu

PHYSICAL THERAPY REFERRAL FORM PHYSICIAN INFORMATION Referring Physician Phone: PATIENT INFORMATION: Patient Name: Phone: Date of Birth: Secondary Phone: MEDICAL INFORMATION: Circle Condition:ACUTECHRONICMedical

How to fill out physical therapy referral form

How to fill out physical therapy referral form

1. To fill out a physical therapy referral form, follow these steps:
2. Start by providing your personal information, including your name, address, phone number, and date of birth.
3. Fill in your medical history, including any previous injuries or conditions that may be relevant to your need for physical therapy.
4. Indicate the reason for your referral and provide any specific instructions given by your healthcare provider.
5. List any medications you are currently taking, as well as any allergies or sensitivities you may have.
6. If applicable, include the name and contact information of your primary care physician or referring healthcare provider.
7. Sign and date the form to confirm that the information you provided is accurate and complete.
8. Check if your insurance information needs to be included on the form, and if so, fill it out accordingly.
9. Review the completed form to ensure all sections are filled out correctly and legibly.
10. Submit the form to the appropriate recipient, which may include your physical therapist, doctor, or insurance provider.

Who needs physical therapy referral form?

1. Physical therapy referral forms are typically required for individuals who wish to receive physical therapy services.
2. Common individuals who may need a physical therapy referral form include:
3. - Patients recovering from orthopedic surgeries or injuries
4. - Individuals with chronic pain or movement issues
5. - Athletes seeking rehabilitation or injury prevention
6. - Workers who have suffered work-related injuries
7. - Individuals with neurological conditions or disabilities
8. It is important to consult with your healthcare provider to determine if a physical therapy referral is necessary in your specific case.

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What is physical therapy referral form?

A physical therapy referral form is a document used to refer a patient to physical therapy services, typically filled out by a healthcare provider.

Who is required to file physical therapy referral form?

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

How to fill out physical therapy referral form?

To fill out a physical therapy referral form, the healthcare provider must provide patient information, reason for referral, diagnosis, treatment goals, and any relevant medical history.

What is the purpose of physical therapy referral form?

The purpose of a physical therapy referral form is to officially refer a patient to physical therapy services in order to address specific health concerns or improve functionality.

What information must be reported on physical therapy referral form?

The information reported on a physical therapy referral form typically includes patient demographics, reason for referral, diagnosis, treatment goals, anticipated duration of therapy, and healthcare provider information.