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PT/MRI
INJURY
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Phone: 412.505.8393
Fax: 412.542.3000
Email:
referrralsteam@premier-comp.com
Physical Therapy / Diagnostic Testing Referral Form
Referred by
* Name
* Company
* Phone
* Fax
Email
General Information
* Referral Type
PT
OT
FCE
MRI
CT
EMG/NCS
OTHER
CHT
AQT
* If Other enter type
Patient Information
* Name
* Address 1
Address 2
* City
* State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Zip
* Birth Date
SS#
* Phone
Cell
Work
Job Title
Gender
Male
Female
* Employer Name
Contact Name
* Address 1
Address 2
* City
* State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Zip
* Phone
Injury Information
* Body Area
Abdomen
Ankle
Arm
Back
Body System
Buttocks
Cheek
Chest
Chin
Collar Bone
Ear
Elbow
Eye
Face
Finger
Foot
Groin
Hand
Head
Heel
Hip
Jaw
Knee
Leg
Lung
Multiple Areas
Neck
Nose
Pelvis
Rib Cage
Scapula
Shoulder
Tailbone
Teeth
Thigh
Thumb
Toe
Tooth
Wrist
* Sub Area
Both
Left Side
Lower Half
Middle
Right Side
Total
Upper Half
* Injury Date
* Diagnosis
* Has the patient sought medical treatment
Yes
No
* If yes where?
ER
Physician
Other
* If Other where?
Referring Physician
Date of initial treatment
* Address 1
Address 2
* City
* State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Zip
Special Requirements
Phone
WC Insurance Billing Information
* Name
Phone
Address 1
Address 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Adjuster
Claim Open
Yes
No
Unknown
Claim Number
Comments
Verification
Attachments
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File Name
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