We’ll use this secure information to contact and onboard your patient to The Mobile Therapy Group.
Physician*
Physician Clinic Name*
Physician Email*
Physician Phone*
Physician Clinic Fax*
Patient Name*
Patient Date of Birth*
Primary Insurance*
Primary Insurance Policy Number*
Secondary Insurance
Secondary Insurance Policy Number
Tertiary Insurance
Tertiary Insurance Policy Number
Date of Referral*
Diagnosis (ICD-10 code)*
Precautions*
Comments
Evaluate & TreatGait TrainingTherapeutic ExerciseAROMPROMAAROMStrength trainingManual TherapyTherapeutic ActivitesNeuromuscular Re-educationTapingEdema managementBalance trainingHome modification/safety assessmentSelf-care management activitiesHome Exercise ProgramCommunity Re-integrationWork conditioningModalitiesWithin provider’s discretionHot/Cold packUltrasoundElectrical StimulationIontophoresisPhonophoresis
Other
Recommended place of treatment* Main clinicPatient preferenceOn-site mobile unitClinician discretion
I hereby certify the prescribed physical therapy is medically necessary for this patient’s plan of care.
Frequency*
Duration*
Last physician appointment date*
Return physician visit date*
Digital Signature Upload:
Signature Date:
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