Rehabilitation Referral Form Referral InformationReferral Agent Name:Insurance Company:Phone #:Fax #:Email Address: Claim Number:Date of Loss / Disability: Date Format: MM slash DD slash YYYY Receiving wage loss or weekly indemnity?YesNoClient InformationClient Name:Date of Birth: Date Format: MM slash DD slash YYYY Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Home Phone #:Cell Phone #:Email Address: Rehabilitation Services Requested:Rehabilitation Services Requested: Full Rehab Case Management (coordination of services with claimant, health care providers, and employer) Interview With Claimant Interview With Treatment Providers - specify below Interview With Employer Interview Lead Physician Arrange Exercise Programs Facilitate Return to Work Arrange Occupational Therapy (Functional Capacity Evaluation, Job Site Analysis, Work Station Review, Clinic Based Occupational Rehab, Progressive Goal Attainment Program, Transferable Skills Analysis) Arrange Independent Therapy Evaluation Arrange Independent Medical Evaluation Treatment Provider to be Interviewed:Comments / RemarksAttach relevant documentation Drop files here or To reduce spam we ask that you copy the characters you see.EmailThis field is for validation purposes and should be left unchanged. Please attach all relevant information with the referral.
