Patient Referral Form

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R
F
eferral
orm
P
I
I
atient:
nsurance
nformation:
______________________________________________
Diagnosis (ICD9) / Accepted Conditions:
First Name
Middle Init
Last Name
____________________________________________________
______________________________________________
____________________________________________________
Address
City, State
Zip
Insurance Company: ___________________________________
(_____)________________________(_____)__________
(
Home Phone
Alternate Phone
Insurance Phone:
_____) ______________________________
Claim/ID #:___________________________________________
______________________________________________
Date of Birth
Gender
P
lease select appropriate box (required to test to tolerance)
Important:
No Restrictions for Functional Assessment
Please choose 1
____________________________________________________________________________
Restrictions as follows:
Work Commercial
P
M
P
Work Commercial
B
I
R
C
ain
anagement
rograms
rain
njury
ehab
enter
Comp. Insurance
Comp. Insurance
(BIRC)
Pain Management Program Evaluation:
Interdisciplinary assessment of chronic pain
Brain Injury Rehab Center Evaluation:
patient (MD, Psych., PT – Work Comp. also
(Danielle Erb MD, PT, OT, SLP, Psych)
includes Vocational & OT)
Day Treatment per recommendations from
Pre-Surgical Pain Management
BIRC evaluation
Evaluation: Interdisciplinary assessment of
patients being considered for SCS, spinal
Neuropsychological Evaluation
fusion or disc replacement (MD, Psych., PT –
Work Comp. also includes Vocational & OT)
Work Commercial
O
S
utpatient
ervices
Comp. Insurance
Pre-surgical Psychological Evaluation:
Vestibular Evaluation
Assess psychological suitability for SCS,
pump, lumbar fusion, or disc replacement
Low Vision Evaluation
Biofeedback Evaluation
Work Comp. Only
W
H
C
ork
ardening/
onditioning
PT Evaluation
OT Evaluation
Disability Prevention Evaluation:
Speech/Language Pathology Evaluation
Interdisciplinary evaluation, typically for
worker’s comp claim that is not progressing
Psychological Evaluation
(MD, Psych, Vocational Eval., two hour PCE)
Signature: _________________________________________
Work Hardening/Conditioning Evaluation:
Identifies suitability for a strengthening
Date: ____/____/_____
program designed to return worker to the job-
at-injury or full-time suitable employment.
Physician Name: ___________________________________
Includes PT, two hour PCE, one hour
vocational evaluation.
Physician Phone: (_____) ____________________________
include Psych
How did you first hear about our clinic? Please Circle
Physician Fax: (____) _______________________________
Inservice Colleague Conference Internet search Mailing
Other _______________________
Please fax completed form to 503-595-7795

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