Practitioner Referral Form - Northwest Functional Neurology printable pdf download

Northwest Functional Neurology

GLEN ZIELINSKI DC, DACNB, FACFN

4035 SW Mercantile Drive, Suite 112 * Lake Oswego, OR 97035

Telephone: 503-850-4526 * Facsimile: 503-908-1555

REFERRAL FORM

**ALL INFORMATION IS REQUIRED FOR THE FORM TO BE COMPLETE**

PATIENT NAME: __________________________________________

DOB: ______________

Address:

______________________________________________________________________________

Home Phone: ________/________/________

Cell Phone: ________/________/________

Insurance Company: _____________________________________________________________

Claim or ID #: ______________________________________

Group #: ___________________

Date of injury or first initial treatment for condition: ________ - ________ - ________

Please note: We ONLY bill out to the following insurance:

BCBS – Regence/PacificSource/Lifewise/Aetna/Providence/ODS

We will bill for MVA if the date of injury is no later than 4mo. WE CANNOT ACCEPT

MEDICARE

REFERRING PROVIDER OR FACILITY:

________________________________________________________________________

Address: _______________________________________________________________________

Phone: ________/________/________

Fax: ________/________/________

_____ REFERRAL FOR FUNCTIONAL NEUROLOGICAL EVALUATION Involves a thorough

functional neurological evaluation, including a history, examination, documentation review, video

nystagmography and computerized dynamic platform post-urography testing as indicated, and

formulation of a rehabilitation protocol. Three (3) visits are required to complete this evaluation.

The third visit involves a report of findings for the patient and referring provider, along with

treatment and demonstration of appropriate rehabilitation exercises and procedures. Referring

providers are welcome to attend the third visit and should make appropriate arrangements with the

patient to coordinate booking and scheduling with our office.

______ REFERRAL FOR EVALUATION AND A COURSE OF TREATMENT Involves the

evaluation protocol described above, followed by a course of care and rehabilitation. This

establishes functional care for complicated and fragile patients and creates a baseline from which

the referring provider can move forward with care. A closing reevaluation and treatment plan

modification is conducted prior to release back to the referring provider. Referring providers are

welcome to attend and observe any or all of these visits.

______ REFERRAL TO TRANSFER CARE Dr. Zielinski is to assume care of the patient

Practitioner Referral Form - Northwest Functional Neurology