Fillable MR identification label Clinic/Physician Office Instructions: This form

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MR identification label Clinic/Physician Office Instructions: This form

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Office Use Only:
MR identification label
Patient Name: _________________________________________________________ Birthdate: ____________________________
Parent(s) : __________________________________________ Cell Phone: ________________________ Email: ________________________________
Outpatient PT & OT Services
Serial Casting Clinic Services
POSH schedulers:
(205) 638-7527
FAX: (205) 638-6740
CHPOSHSchedulers@childrensal.org
Outpatient PT Intensive Therapy
P
OSH schedulers:
(
205) 638-7527
FAX: (205) 638-6740
CHPOSHSchedulers@childrensal.org
OT for CBIT Program for
Tics & Tourette’s
Scheduling & Questions:
(205) 638-6820
FAX: (205) 638-6063
PT OT
Vestibular/Balance Disorders
POSH
schedulers:
(205) 638-7527
FAX: (205) 638-6740
CHPOSHSchedulers@childrensal.org
Referring
Physician: (please print) __________________________________________________________________________________
Referring P
hysician Address: _______________________________________________ Office Phone:___________________________
________________________________________________FAX:__________________________________
Please note: Reason for referral, diagnosis and physician’s signature are required from the physician’s office prior to the patient being seen for
either Physical Therapy and/or Occupational Therapy
Patient referred for:
Occupational Therapy Evaluation & Treatment Physical Therapy Evaluation & Treatment
Occupational Therapy Orthotics
Physical Therapy Orthotics
Reason(s) for referral:
Fine motor delay
Difficulty walking/gait abnormality/toe walking
Handwriting problems
Gross motor delay
Feeding difficulty
Lack of coordination/balance
Muscle weakness/Specify:
Muscle weakness/Specify:
Hand or upper extremity orthopedic problems
Lower extremity orthopedic problems
Torticollis
Torticollis
Sensory problems/sensory integration disorder
Orthotics: Solid AFO, Hinged AFO, SMO, FO, Other:
Pain in upper extremity/hand/Specify:
Pain in lower extremity/Specify:
Upper extremity serial casting, and orthotics as needed
Lower extremity serial casting, cast shoes, knee immobilizers
and orthotics as needed
Splinting: specify:
Mobility device: crutches, walker, canes
Other: specify:
Other: specify:
Diagnosis (
please list ICD-10 code): ________________________________________________________
Scheduling urgency due to: post- surgical therapy needs post- BOTOX failure to thrive
Precautions (Concerns/contraindications): _________________________________________________________________________
Has child seen a therapist here before? Yes/Name: _______________________________ No
Current Medications (list): ________________________________________________________________________________________
MRSA Positive? Yes No CMV active? Yes No
Type of Insurance:_________________________________________ Contract #: ___________________________________________
Insurance au
thorization number:____________________________________ (if Medicaid, please provide Medicaid referral)
Physician sig
nature:________________________________________Date:____________Time: _______________________
Form # 2197 – Revised 11/01/2019 Page 1 of 1
Referral for Physical Therapy & Occupational Therapy
Clinic/Physician Office Instructions: This form must be faxed as indicated below
If Demographics sheet is attached, fill in the Patient Name and Birthdate only
Please attach Medicaid referral. For insurance, complete the form below.
*DT0185*
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MR identification label ClinicPhysician Office Instructions: This form

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Completed 9 May 2022

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