Outpatient Adult Physical Therapy Referral Form - med nyu 2026

1. Click ‘Get Form’ to open the Outpatient Adult Physical Therapy Referral Form in the editor.
2. Begin by entering the date at the top of the form. This helps track when the referral was made.
3. Fill in the patient's name, including last and first names, along with their date of birth and gender. Ensure accuracy for proper identification.
4. Provide the patient's address and phone numbers (home, work, and cell) to facilitate communication.
5. Input primary and secondary insurance details, including policy IDs and insured names, to ensure coverage for therapy services.
6. Document the medical diagnosis along with the corresponding ICD code to clarify the reason for referral.
7. Select applicable physical therapy evaluation and treatment options by checking relevant boxes.
8. Indicate any precautions related to the patient's condition that therapists should be aware of during treatment.
9. Complete physician information by printing their name, specialty, NPI number, license number, address, office telephone, and fax number.
10. Finally, ensure that the physician signs the form before submission to validate it.

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