Phone:
(866)530-3940
Fax:
(904)541-0616
E-mail:
referrals@htpn.com
HTPN
Specialty Services 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
*
Does the patient speak English?
Yes
No
*
If no, is translation set up or authorized?
Yes
No
Notes:
Patient Contact Info
*
Street Address
Apt
(if any)
:
(ex. 15A)
(cont.)Street Address
(if needed)
*
City
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
*
Zip
(ex. 12345-6789)
*
Home Phone:
(ex. (555)555-1234)
Alt. Phone:
(ex. (555)555-1234)
Employment Information
*
Occupation:
*
Employer:
Phone:
(ex.(555)555-1234)
*
Job Description Available?
Yes
No
Physician Information
*
Physician Ordering Services:
Dr
Phone:
(ex.(555)555-1234)
Fax:
(ex.(555)555-1234)
Street Address:
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
(ex. 12345-6789)
Diagnosis and Treatment
*
Diagnosis:
*
Service Required:
Functional Capacity Evaluation
Ergonomic Evaluation
Job Site Analysis / Physical Demand Analysis
ICD9 Code:
Next Physician's Appointment:
(MM/DD/YYYY)
*
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
*
Name:
*
Phone:
(ex.(555)555-1234)
Fax:
(ex.(555)555-1234)
*
Relationship to patient:
*
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
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
*
Zip
(ex. 12345-6789)
Nurse Case Manager (NCM)
(If different from Responsible Person)
Name:
Phone:
(ex.(555)555-1234)
Fax:
(ex.(555)555-1234)
Email Address:
Adjuster
*
Name:
*
Phone:
(ex.(555)555-1234)
*
Fax:
(ex.(555)555-1234)
Email Address:
Other Contact
Name:
Relationship to Patient:
Phone:
(ex.(555)555-1234)
Reason for Service
*
Reason for Referral:
(ex. 'To assess current physical abilities')
*
Current Duty Status:
*
Lifting Requirements:
*
Lifting Restrictions:
*
What time frame does this referral need to be placed?
*
With whom do we schedule the service?
Patient
NCM
Attorney
MD
Other
*
Will the patient require transportation?
Yes
No
*
If yes, would you like HTPN to assist with set-up?
Yes
No
Comments:
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