PT/OT Referral Form

Document Information
  How to complete a fillable form.
Title PT/OT Referral Form

Attending Providers use this form to refer injured workers for physical or occupational therapy to progressively increase activity and exercise, or activity tolerance, develop home or self-care programs, and perform work activity conditioning. Explains to therapists your specific requests and expected follow-up therapy reports.

Document number F252-099-000
How to get this document
Alt Language(s)
Valid dates 10/2013
Contact information Claims for Job Injuries , Managing Injured Workers' Claims
Websites For Medical Providers

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