Refer to TRS

DOCTOR'S OFFICES / SELF REFERRAL / WORKERS COMP

For your convenience, we have attached a copy of our prescription/referral form.  To download and print this document, please Click Here or complete the form below

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Clinic Location	Tampa Pinellas Park Lakeland
Services	PT FCE Work Conditioning ERGO Assessment Additional PT/OT Home Care PT Pre/Post Offer Physical Assessment
Date
Insurance Information
Insurance Company
Name Of Referral Person If Not CM or Adj
Referral Person Phone w/ Extension
Insurance Company Fax
Billing Address
Billing City
Billing State
Billing Zip
Adjuster
Adjuster Email
Adjuster Phone w/Ext.
Case Manager
Case Manager Email
Case Manager Phone w/Ext.
Claim #
Patient Information
Patient First Name
Patient Last Name
Patient Home/CellPhone
Patient Work Number
Patient Address
Patient City
Patient State
Patient Zip
Patient Birthdate
Patient Social Security Number
Date of Injury
Work Status	Full Time Part Time Out of Work
Occupation
Special Instructions
Employer Information
Employer
Employer Address
Employer City
Employer State
Employer Zip
Employer Phone
Employer Fax
Physician Information
Physician First Name
Physician Last Name
Physician Phone
Physician Fax
Diagnosis
Number of PT Visits
Scripts	Call MD to obtain RX Patient has copy
Attorney Information
Attorney Represented	Yes No Not known at this time
Claimant Attorney Name
Claimant Attorney Phone
Claimant Attorney Fax
Defense Attorney Name
Defense Attorney Phone
Defense Attorney Fax
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