Physical Therapy Referral

Physical Therapy Referral
Referring Provider Information
Name

First NameLast Name
Practice Name
NPI Number
National Provider Identifier
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Primary Diagnosis
ICD-10 Code
(if available)
Referral Details
Referring for (check all that apply):

Other
Referral Details
Physical Therapy Frequency
Duration of Care:

Other
Medical Necessity Certification

(per Texas PT Law)
I certify that physical therapy is medically necessary for the patient above. This referral is made in accordance with Texas Administrative Code §322.1, and complies with Texas Physical Therapy Practice Act.
Referring Provider Signature:
Typed full name acts as e-signature.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Referring Provider Information