Driver Evaluation/training Referral Form - Rochester
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1KALEIDA HEALTH/DEGRAFF HOSPITAL/ROCHESTER REHABILITATION CENTER
DRIVER EVALUATION/TRAINING REFERRAL
NAME:_____________________________________DOB:________SEX: M__ F__ PHONE:______________________
ADDRESS:___________________________________CITY:______________________STATE:______ZIP:__________
Referral for:
Driver Evaluation
Driver Training if indicated
Equipment Eval. For Driving
Equipment Eval. for Passenger
Vehicle Consult
Equipment Inspection
Did individual drive prior to disability?
YES
NO. If yes, how long? __________________
Does individual have valid New York State Driver’s License?
YES
NO
Does individual have valid New York State Learner’s Permit?
YES
NO
-
Medical Summaries required for all driver evaluation referrals
Please include admission and discharge summaries
if hospitalized in the past year.
Mental Retardation or Learning Difficulties Diagnosis – Include most recent psychological testing.
Brain Injury Diagnosis – Include a neuropsychological evaluation and medical discharge reports.
Loss of Consciousness – Include a neurospsychological evaluation if any incident has occurred within past 12 months.
LIST DISABLING CONDITIONS (See above for details of medical reports that should accompany referral):
__________________________________________________________________________________________________
Does the individual have Health Insurance?
YES
NO
INSURANCE COMPANY
YES
NO
________________________________ PRIOR APPROVAL NEEDED?
SUBSCRIBER #_________________________ AUTHORIZATION #_________________________________
Is the individual a Medicaid Recipient?
YES
NO
Has individual participated at Driver Evaluation/Training before?
YES
NO
COMMENTS:______________________________________________________________________
Return completed referral to:
DRIVER EVALUATION/TRAINING SERVICES
Rochester Rehabilitation Center
1000 Elmwood Avenue, Suite 600
Rochester, NY 14620-3097
TOLL FREE PHONE: 1-877-823-7483
FAX # (585) 295-8029
Referred by (
): _______________________________________________ Date:___________
please print name
Agency/Program:__________________________________Address:__________________________________
City:____________________________State______Zip:____________Phone:___________________________
A PHYSICIAN’S ORDER FOR AN OCCUPATIONAL THERAPY EVALUATION OF FUNCTIONAL ABILITY TO DRIVE IS REQUIRED. THIS
FORM MAY SERVE AS ORDER IF PHYSICIAN’S SIGNATURE APPEARS BELOW. (IF PREFERRED, ATTACH PRESCRIPTION.)
___________________________________________________
___________________________________________________
Physician’s Signature
Date
REGISTRATION #
DR/FC: h:\gruber\W\DriverBUFreferral, rev. 02/2005
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