Short Term Rehab Consultation Form

Patient Information

Post Title

Name

First Last

Date of Birth

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Care Physician Information

Physician Name:

Physician’s Office Phone Number:

Physician’s Email Address:

Referring Hospital (if any):

Date of Discharge from Referring Hospital:

Medical Information

Reason for Hospitalization:

Current Medical Condition/Diagnosis:

Type of Therapy Required (check all that apply):

24/7 Clinician/Nursing Care

Physical Therapy

Occupational Therapy

Speech Therapy

Wound Care

IV Therapy

Nutritional Support

Other

Insurance Information

Primary Insurance Provider:

Policy Number:

Group Number:

Is Medicare your primary insurance?

Do you have secondary insurance?

If yes, please provide the name of the secondary insurance provider:

Eligibility Criteria

Were you hospitalized for at least 3 days in the last 30 days?

If yes, which hospital?

Admission date:

Discharge date:

Additional Information

Please provide any other details that may assist in evaluating your application: