PHYSICAL / OCCUPATIONAL THERAPY PROCEDURES
I certify that the above marked therapy/rehabilitation service is medically necessary:
Physician’s Signature Date
(Medicare Required)
Frequency: q 1x/Wk q 2x/Wk q 3x/Wk q 4x/Wk q 5x/Wk
Duration: q 1Wk q 2Wks q 3Wks q 4Wks q q Therapist Discretion
FREQUENCY/DURATION
WORKER’S COMPENSATION SERVICES
PROGRAM GOALS
q Relieve Pain
q Increase ROM
q Increase Strength
q Increase Endurance
q Decrease Edema
q Improve Functional Skills
Patient’s Name: Date of Birth:
Diagnosis:
Special Instructions:
Home Phone: Work Phone: Cell:
Primary Insurance:
Secondary Insurance:
*copy of insurance card attached
Referring Physician: Office Contact:
Office Phone: Office Fax:
PATIENT INFORMATION
q Evaluate & Treat
q Modalities
q Therapeutic Exercise
q
Home Traction Unit
q Home TENS Unit
q HEP
q McKenzie Back Program
q Manual Therapy
q Other
DO NOT EMAIL PRESCRIPTION The electronic prescription form is provided for your convenience. With respect to responding to this form, please do not send the pre-
scription via email. Please populate, print and sign a hardcopy that may be faxed, mailed or hand delivered to the clinic.
q Work Hardening / Conditioning q Functional Capacity Eval (FCE)
MEMPHIS INDUSTRIAL
REHABILITATION CENTERS
EMPOWERING WORKERS
www.memphispt.com
q
Arlington
6050 Airline Road Suite 106
Arlington, TN 38002
T. 901-867-8989
F. 901-867-8757
q
Bartlett/ MIRC (FCE)
6600 Stage Rd, Ste 129
Bartlett, TN 38134
T. 901-371-0732
F. 901-371-0859
q
Downtown
440 North Front St., Suite 102
Memphis, TN 38105
T. 901-577-9484
F. 901-577-9483
q
Olive Branch (FCE)
7501 Goodman Road, Ste 1
Olive Branch, MS 38654
T. 662-890-3382
F. 662-890-3385
www.crosscreekpt.com
q Southaven
7065 Airways Blvd., Ste 110
Southaven, MS 38671
T. 662-349-8997
F. 662-349-8987
www.kinetixpt.net
q East Memphis/ MIRC (FCE)
5039 Park Ave, Ste 102
Memphis, TN 38117
T. 901-818-9746
F. 901-818-9741
q
Millington
8390 Highway 51 N. Suite 101
Millington, TN 38053
T. 901-872-6422
F. 901-872-6497
DESOTO COUNTY PHYSICAL THERAPY
MISSISSIPPI
Mississippi - Tennessee
TENNESSEE
Downtown
(MIRC)
East Memphis
Arlington
269
(MIRC)
Bartlett
JUST A REMINDER:
Please arrive 15 minutes before your scheduled appointment to complete the necessary paperwork.
Evaluations (1st visit) usually last 1 to 2 hours.
WHAT TO WEAR:
Please wear/bring comfortable clothing and sneakers including T-shirts and shorts or sweatpants.
WHAT TO BRING:
Please bring this referral slip with you on your rst visit. Appropriate insurance claim form or PPO/HMO referral slip or workers
compensation employer information including claim # or no fault insurance information.
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