Vestibular therapy 2025

1. Click ‘Get Form’ to open the Outpatient Vestibular Physical Therapy Referral Form in the editor.
2. Begin by entering the date at the top of the form. Next, fill in the patient's name, date of birth, gender, and social security number in the designated fields.
3. Provide the patient's address and phone numbers (home, work, and cell) to ensure accurate contact information.
4. Input primary and secondary insurance details including policy ID numbers and insured names to facilitate billing processes.
5. Document the medical diagnosis and select the appropriate vestibular diagnosis from the provided options. Ensure you check all relevant conditions.
6. Indicate if a prescription for evaluation and treatment is needed along with its onset date.
7. For vestibular psychology options, select any applicable services such as educational series or therapy types based on patient needs.
8. Finally, have the physician complete their information including name, specialty, NPI number, license number, address, office telephone, fax number, and signature.

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