Healthrite Physical Therapy

Date*

Consumer's Name*

Consumer's Phone*

Consumer's Disabilities*

Requestor's Name*

Requestor's Phone*

Field Office*

Please be advised that the consumer will be scheduled for the requested evaluation stated below and a Notification of Appointment Letter will be forwarded by email/mail. Please call our office if you have any questions.

We appreciate you considering us for this referral.

Physician's Visit - 99204 - 1 service
Drug Screen - 80100 - 1 service
Physical Therapy Evaluation - 97001 - 1 service
Drug Screen Clinical Pathology - 80500 - 1 service
Functional Capacity Evaluation - 97750 - 20 services

Please select the reason for Functional Capacity Evaluation.

To assess whether an injured patient can return to a previous job.
To assess the client's safe work tolerance levels, the job is unspecified.
To assess the client's ability to perform a specific job.
To assess the presence of symptom magnification.
To assess the validity or consistency of client's effort.

Specific Job Title*

Comments

Department of Assistive Rehabilitative Services (DARS)
Referral Form

Office Hours: 8:30 AM to 5 PM Monday to Friday

Department of Assistive Rehabilitative Services (DARS) Referral Form

Office Hours: 8:30 AM to 5 PM Monday to Friday

Department of Assistive Rehabilitative Services (DARS)
Referral Form