Provider Referral Form

Virtual Pulmonary Rehabilitation Program Provider Referral Form

(T) 602-362-4466 (F) 928-441-8421
Please include the following information:
- The signed referral form
- The patient's most recent office note with updated medications list
- The patient's insurance information (front and back copy of cards if available)
- A copy of the patient demographic sheet containing any available patient contact information
You will be able to upload documents at the end of this form
Patient's Name*
Patient's DOB*

MonthDayYear
Date
Patient's Phone Number*
Please enter a valid phone number.
Patient's Email*
example@example.com
Reason for Referral:*

COPD: Chronic BronchitisCOPD: EmphysemaCOPD: Alpha-1 Antitrypsin DeficiencyInterstitial Lung DiseaseBronchiectasisPost COVID-19 Lung DiseaseAsthma
Most recent pulmonary function test results (if available):
FEV1:
FEV1% predicted:
FVC:
FVC% predicted:
FEV1/FVC % predicted:
6-Minute Walk Test Results (if available):
Distance:
Supplemental O2:
Assistive Device Used:
Provider's Orders:
Physical Therapy Initial Evaluation and Treatment:*

I Agree
Is the patient prescribed supplemental oxygen?*

YesNo
Does the provider give permission for physical therapists/respiratory therapists to instruct the patient to titrate oxygen appropriately during exercise to maintain SpO2 >88-90%?*

YesNo
SIGNATURE REQUIRED FOR REFFERAL
Provider's Name:*
Date:*

MonthDayYear
Date
Provider's Clinic*
Provider's Signature:*

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Medical Assistant Name and Contact
Please upload any additional files such as the patient’s most recent office note with updated medications listed, and the patient’s insurance information (front and back copy of cards if available)

Cancelof
Should be Empty:

Virtual Pulmonary Rehabilitation Program Provider Referral Form

Most recent pulmonary function test results (if available):

6-Minute Walk Test Results (if available):

Provider's Orders:

SIGNATURE REQUIRED FOR REFFERAL