Therapy Referral Form

ADVANCED THERAPY OPTIONS NETWORK

(Offering In-Home Physical Therapy Services)

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In conjunction with our prosthetic intervention, in-home physical therapy is given to our patients to help improve their rehabilitative outcomes. Advanced offers physical therapy services for amputees statewide using our network of quality independent providers. In-home physical therapy is designed to be a convenient alternative to the patient making multiple trips to a fixed therapy for service. For patients, the referral process is easy. Advanced completes the therapy referral form below and submits it to the therapy provider, who obtains the insurance/physician approvals for service. Patient Patient's Name: Patient's Address: City, State, Zip: , AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Patient's Phone: Referring Physician Physician's Name: Physician's Address: City, State, Zip: , AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IO KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Physician's Fax: Physician's Phone: Prosthetics Right extremity Left extremity Bilateral   Above Knee Above Knee     Below Knee Below Knee     Symes Symes     Partial Foot Partial Foot     Above Elbow Above Elbow     Below Elbow Below Elbow   (Please Mark the Appropriate Box) Pre-Prosthetic Consultation Prosthetic Consultation   Other