Geisinger form 2026

1. Click ‘Get Form’ to open the Geisinger Outpatient Rehabilitative Therapy Services Referral Form in the editor.
2. Begin with Section 1, where you will need to fill in the required information such as the Rehab Provider Facility Name, Member Information including Last Name, First Name, and MI. Ensure all fields marked with an asterisk (*) are completed to avoid processing delays.
3. Next, provide details about the Referring Physician including their First and Last Name, along with their Health Plan Provider number and the patient's Date of Birth (DOB).
4. Indicate the Service Requested by selecting from options like PT (Physical Therapy), OT (Occupational Therapy), or ST (Speech Therapy) and specify the Site of Service.
5. In Section 2, describe the Functional level prior to the current problem and outline Current Problems/Duration. You can also attach an evaluation if needed.
6. Finally, set your Goals for therapy and complete the Plan of Care section. Don’t forget to sign and date at the bottom before submitting.

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