Assistive Technology Center Referral Form
This form should be completed by your physician to make a referral for our Assistive Technology Center.
Patient Information
Name: Date of Birth: SSN:
Address:
City: State: ZIP Code:
Home Phone: Cell Phone: E-mail:
Diagnosis and ICD-10 Code:
Assistive Technology
OT or ST for Assistive Technology Evaluation and Treatment
ST for evaluation and treatment for speech generating device
OT or ST for electronic device access in the AT Center
Driving
OT Evaluation and Treatment for Driver Rehabilitation/Community Mobility
Driver’s License Learner’s Permit License/Permit #: Expiration:
Has the patient had a seizure or episode withing the last year? Yes No Date:
Current medications that may affect safe driving:
Do you recommend any driving restrictions? Please specify below:
Seating and Mobility
PT or OT Evaluation and Treatment for Seating and Mobility
Pressure Ulcer/Pressure Map
Seating Clinic Visits
Do you know your Equipment Supplier? If so, please indicate below:
Company Name : Phone:
Insurance Type: Medicare Medicaid Private Insurance VR VA
Referral Source
Physician Name: Phone: Fax:
Address:
City: State: ZIP Code:
Please attach the patient’s most recent medical history and physical or chart note.
Physician Signature: Date:
*Must have MD signature (cannot be a proxy). Appointment will not be scheduled without signature.
Please fax this form (along with patient’s medical history & physical) to 404-350-7356.
Patients who are not contacted within three business days should call 404-355-1144 and ask for Outpatient Scheduling.
