REGIONAL
REFERRAL & INSURANCE VERIFICATIONREGIONAL
REFERRAL & INSURANCE VERIFICATION
r Personalized Physical Therapy r Customized Industrial Rehabilitation r Hand Therapy
r Functional Capacity Exams r Work Hardening r Ergonomic Programs
r On-Site Programs r Toll Free 888-827-6361 r Web Site www.Rehabatwork.com
Baltimore 7501 Pulaski Hwy. Baltimore, MD. 21237 410-866-3855 (fax) 410-866-3877Rockville 51 Monroe St., PLW#6 Rockville, MD. 20850 301-251-3757 (fax) 301-251-3731
Lanham 8240 Professional Pl. Lanham, MD. 20785 301-306-4500 (fax) 301-306-4503
Waldorf Park Waldrof Center, 11811 Park Waldorf Lane, Waldorf, MD. 20601 301-893-2360 (fax) 310-893-0609
Lusby 11855 HG Truman Rd., Lusby, MD. 20657 410-326-3432 (fax) 410-326-2493
Manassas 8809 Sudley Rd.,Suite 102 Manassas, VA. 703-392-7508 (fax) 703-392-6710
Alexandria 2500 Van Dorn Street Alexander, VA. 703-933-1700 (fax) 703-933-8300
REGIONAL REFERRAL & INSURANCE VERIFICATION
WORKERS’ COMPENSATION
DATE: ____________________________________________ INSURANCE:__________________________________
PATIENT: ___________________________________WC CASE #:________________________
ADDRESS: __________________________________________ ADDRESS: ___________________________________
TELEPHONE #: _____________________________________ CASE MANAGER: ____________________________
SSN#: ______________________________________________ PHONE #: __________________________________
DIAGNOSIS: PURPOSE:
Dear Authorizing Agent or Physician: This letter is written confirmation concerning the above claimant. You, as an authorizing agent have approved the claimant to attend REHAB AT WORK and to participate in the following rehabilitation program(s): SECOND CANCELLATIONS AND NO SHOWS FOR FCE’S WILL BE CHARGED A FEE OF $250.00.
qFUNCTIONAL CAPACITY EVALUATION (99456, 97750 - 16 units) @ $ _____________
qWORK HARDENING PROGRAM (billed w/weekly notes #97799-06 @ $ ______________
q WORK CONDITIONING PROGRAM (additionally billed w/weekly @ $ ______________
notes, 97799-06 and 97545 - 1 hour, 97546 – each additional hour)
qPHYSICAL THERAPY EVALUATION AND/OR TREATMENT @ $ ______________
qMAINTENANCE "READY TO WORK" PROGRAM @ $ ______________
(an after therapy program to maintain employable functional levels @ $175/3 months)
qJOB SITE VISIT/JOB TASK ANALYSIS @ $ ______________
qFUNCTIONAL RESTORATION PROGRAM (a flat rate therapy program for @ $ ______________
sub-sedentary & sedentary patients: a two-(2) 3-week graduated rehab program)
Charges will be per REHAB AT WORK’s customary fees unless otherwise noted on this form. This form will accompany all HCFA 1500 forms for reimbursement to any authorized agent. PLEASE SIGN OR INITIAL THIS FORM AND FAX IT TO THE APPROPRIATE OFFICE OR OUR CORPORATE OFFICE. WE WILL CONTACT YOUR PATIENT WITHIN 48 HOURS OF YOUR REQUEST TO SCHEDULE HIM/HER.
CORPORATE OFFICE: 301-838-2040 OR 1-888-827-6361 (FAX) 301-838-2041