Non-Medical Provider Referral Form - Physical Therapy - Medical Fitness

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Secure Fax – 888-624-3107 Phone: 507-259-7570
Non-Medical Provider Referral Form
Patient Name: ____________________________________ Hospital Clinic # _____________
Date of Birth: ___________ Phone number: _________________
Primary insurance: ______________________________________ # if available ____________
Address: ______________________________________________________________________
Primary Medical Provider Name: _______________________________ Mayo or Olmsted
Service recommended:
____ Physical Therapy (No MD order Required)
____ Occupational Therapy (No MD order Required)
____ Medical Nutrition Therapy – Dietician (Must have MD order for this)
____ Forever Strong (245D ILS (CADI) and Specialist Services (DD) Life Wellness Program)
-
The medical conditions that supports the need for the above services are:
________________________________________________________________________
________________________________________________________________________
_______________________________________
I am referring this client for therapy services
______ In their home
______ For aquatic therapy
______ To be seen at Exercisabilities clinic
______ I certify that the above is not currently receiving any home care services that qualify
for Medicare Part A services and would like them to be seen under Medicare B, commercial
insurance, or private pay means.
Referral source Name: _____________________ Phone: __________Fax:______________
We do not require any other referral forms or information. We can call and set up the visit with the client and
verify all insurances. We appreciate your referral!

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