Nyu langone lymphedema 2026

1. Click ‘Get Form’ to open the nyu langone lymphedema referral form in the editor.
2. Begin by entering the date at the top of the form. Then, fill in the patient's name, including last and first names.
3. Next, input the patient's date of birth and select their gender by circling 'F' or 'M'. Include the patient's Social Security number.
4. Provide the patient's address and phone numbers (home, work, and cell) in the designated fields.
5. Fill out insurance information by entering primary and secondary insurance details along with policy IDs and insured names.
6. Select the appropriate lymphedema diagnosis/ICD code from the options provided.
7. Indicate which physical therapy evaluation and treatment options are applicable by selecting from the list.
8. Specify which extremity is affected by selecting from right arm, left arm, right leg, left leg, or other.
9. Complete any precautions needed and indicate frequency/duration of treatment.
10. Finally, have the physician print their name, specialty, NPI number, license number, UPIN, address, office telephone, office fax, and sign at the bottom of the form.

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