Physician Referral Form


614 North Sixth Street, Ste A Springfield, IL 62702 217 522 3380 Fax 217 522 3382

		2717 W Monroe Springfield, IL 62704 217 787-8720 Fax 217 787-8723

	1750 E. Lakeshore Drive Decatur, IL 62521 217 425-2732 Fax 217 425-4778

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Date:__________________________________________________________________

Diagnosis:______________________________________________________________

Fequency / Duration__________________________ ICD-9 Code____________

____ PT Evaluation and Treatment
____OT Evaluation and Treatment
____Work Hardening Evaluation and Treatement
____Funcional Capacity Evaluation
____Post Offer Screen / Fitness for Duty Evaluation
____WorkSTEPS Evaluation
____Ergonomic Assesment
____Job Site Analysis
____B200 Isokenetic Low Back Evaluation

TREATMENT

____Therapeutic Exercise
____Low Back / Neck Program
____Back School
____Home Exercise Only
____ROM / Stretching
____Moist Heat
____Cryotherapy
____Ultrasound
____Electronic Stimulation
____Iontophoresis
____TENS unit and instruction
____Other __________________________________________________________________________________ __________________________________________________________

I certify that prescribed therapy is medically necessary for this patient’s condition.

Physician Signature______________________________________________________
Substitution Permissible / Substitution Not Permissible


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