Rehabilitation Services Referral Munson Healthcare
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REHABILITATION SERVICES
See reverse for address and phone info.
Form #2245 (02/15)
REFERRAL / ORDER
ADVANCE WOUND CENTER
Page 1 of 2
r Wound Management
r Hyberbaric Oxygen
r
AQUA THERAPY
Benzonia Physical Therapy
NAME:__________________________________________________________
Kalkaska Memorial Health Center
Munson Community Health Center
Munson Healthcare Cadillac Hospital
BIRTHDATE:
PHONE:
Munson Healthcare Grayling Hospital
DIAGNOSIS CODE(S):
West Shore Medical Center
r
AUDIOLOGY
(If unknown, please provide the information below)
Kalkaska Memorial Health Center
CONDITION / SYMPTOM / IMPAIRMENT:
Kingsley
Munson Healthcare Grayling Hospital
Munson Medical Center
Paul Oliver Memorial Hospital
r
BRAIN INJURY & COGNITIVE REHAB
Includes PT, OT and Speech
ETIOLOGY:
Munson Community Health Center
l
r
HAND THERAPY
BODY SITE(S):
Bear Lake Clinic
Interlochen Therapy Clinic
ONSET:
r
r
r
ACUTE
CHRONIC
LATE EFFECT
Kalkaska Memorial Health Center
Munson Community Health Center
(DATE if known)
Paul Oliver Memorial Hospital
West Shore Medical Center
r
OCCUPATIONAL THERAPY
r EVALUATION & THERAPY TREATMENT (indicate specifics below)
Bear Lake Clinic
Interlochen Therapy Clinic
r Continue current program
Kalkaska Memorial Health Center
r Other: _____________________________________________________
Munson Healthcare Cadillac Hospital
Munson Healthcare Grayling Hospital
FREQUENCY & DURATION: ____________x per week for__________weeks
Munson Medical Center
(Required for BCBS)
Paul Oliver Memorial Hospital
West Shore Medical Center
PEDIATRIC THERAPY
SPECIALITY PROGRAMS / INTERVENTIONS:
r Feeding Therapy (Munson Hospital)
r Occupational Therapy
r Driver Assessment Program (OT)
r Pelvic Dysfunction Treatment:
r Physical Therapy
r Speech Therapy
r OT Evaluation & Training
r Incontinence r Pelvic Pain
r
r ENG
r SAEBO
PHYSICAL THERAPY
r Functional Capacity Test
r Speech Generating Device
Bear Lake Clinic
r Hearing Aid
r Train Your Brain Program
Benzonia Physical Therapy
Empire Physical Therapy
r Job Site Evaluation (OT)
r Vestibular Treatment
Interlochen Therapy Clinic
r Low Vision Program (OT)
r Videofluoroscopy (ST)
Kalkaska Memorial Health Center
r Lymphedema Treatment
r Work Readiness Program
Kingsley
r Orthotic(s)
(includes PT & OT Evaluation)
Mancelona Physical Therapy
Type:____________________
r Wound Management
Munson Community Health Center
Munson Healthcare Cadillac Hospital
Munson Healthcare Grayling Hospital
Munson Medical Center
INSTRUCTIONS / PRECAUTIONS:
Paul Oliver Memorial Hospital
West Front Physical Therapy
West Shore Medical Center
r
SPEECH THERAPY
Kalkaska Memorial Health Center
Munson Healthcare Cadillac Hospital
Munson Healthcare Grayling Hospital
Munson Medical Center
Paul Oliver Memorial Hospital
West Shore Medical Center
r
VITAL STEP- FITNESS- EXERCISE
Munson Community Health Center
West Shore Medical Center
r
WORK READINESS (PT & OT)
APPOINTMENT DATE:
TIME:
Munson Community Health Center
Physician/PA Name
Signature
Date/Time
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