Make a Referral - Therapy Direct

Name of Person Submitting Referral*
Injured Worker's Name:*
Injured Worker's Last 4 Digits of Social Security Number
Please enter a number from 0000 to 9999.
Date of Birth
MM slash DD slash YYYY
Male/ Female*
Language
Home Address*
Home Address Line 2 City State Zip
Injured Worker's Phone*
Cell
Work Address
Work Address Line 2 City State Zip
Work Phone Number
Injured Worker's Email
Employer/Work*
Date of Injury*
MM slash DD slash YYYY
State of Jurisdiction*
Any Surgeries Related to this Claim*
If applicable, date of surgery.
MM slash DD slash YYYY
Work Status
Approved Body Part for Treatment*
Region for Treatment
Diagnosis/ICD-10
Select Authorized Sevices*
- Physical Therapy
- Occupational Therapy
- Certified Hand Therapy
- Aquatic Therapy
- Work Conditioning
- Work Hardening
- Functional Capacity Evaluation (FCE)
- Impairment Rating
Authorized number of visits for treatment*
Duration
Transportation Required
Interpreter/ Translator Needed
Referring Physician*
Referring Physician Address
Street Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referring Physician Phone
Referring Physician Fax
Payor Name*
Claim Number*
Claims Billing Address
Street Address Line 2 City State / Province / Region ZIP / Postal Code Country
Adjuster Name*
Adjuster's Email
Adjuster's Phone*
Adjuster's Fax
Case Manager's Name
Case Manager's Email
Case Manager's Phone
Case Manager's Fax
RX
Max. file size: 100 MB.
Other Attachment 1
Max. file size: 100 MB.
Other Attachment 2
Max. file size: 100 MB.
Other Attachment 3
Max. file size: 100 MB.
Additional Instructions/ Comments
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