Phone: (866)530-3940
Fax: (904)541-0616
E-mail: referrals@htpn.com

HTPN Direct Service Referral Form

* Denotes a required field

Patient Information

*First Name:

MI:

*Last Name:

*Date of Birth:

(MM/DD/YYYY)

*SSN:

(ex. 555-55-5555)

*Gender:

Male Female

Patient Contact Info

*Street Address		Apt (if any): (ex. 15A)
(cont.)Street Address (if needed)
*City	*State	*Zip (ex. 12345-6789)

Home Phone:	(ex. (555)555-1234)
Alt. Phone:	(ex. (555)555-1234)

Employment Information

Physician Information

Physician Ordering Services:

Phone:

(ex. (555)555-1234)

Fax:

(ex. (555)555-1234)

Street Address:
City	State	Zip (ex. 12345-6789)

Diagnosis and Treatment

*Diagnosis:
*Service Required:	Physical Therapy Occupational Therapy Speech Therapy Aquatic Therapy Massage Therapy Physical Reconditioning
ICD9 Code:
*Number of authorized visits:
Rx Frequency:
Rx Duration:
Is the Prescription Faxed?	Yes No
If "No", would you like HTPN to contact the physician for Rx?	Yes No

Authorization & Billing Information

Person Responsible for Authorization

*Is therapy authorized?

Yes No

*Date of Injury:

(MM/DD/YYYY)

Date of Surgery:

(MM/DD/YYYY)

*Claim Number:

Secondary Claim Number:

*Mail Claim to (Payor Name):

*Claims (Payor) Street Address:
*City	*State	*Zip (ex. 12345-6789)

Nurse Case Manager (NCM)

(If different from Responsible Person)

Adjuster

Other Contact

Special Instructions