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WorkAbility Network Referral Form
Please fill in the required boxes and any
additional information that will help us serve your needs. You can
also fax your referral to (513) 672-2552 and let WorkAbility Network
handle the rest. Thank you! * Denotes required
field.
Worker
Information | |
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Authorized # Visits
Start Date:
End Date:
Instructions (Pre-Authorization #
, etc.)
Check service(s) requested
Workability Fitness
Screen |
An objective, post-offer screen of musculoskeletal health and workabilities to promote
job safety and productivity. |
Transitional Work
Therapy (W0637) |
Therapeutic activities at
the work site to accommodate and progress an injured worker with medical restrictions back to productive duty in a
targeted job. |
Physical Therapy |
Individualized physical therapy services at a convenient clinic that is focused on return to work goals during the acute and sub-acute recovery phase. Inclused hand/wrist therapy, vestibular, aquatic, and back rehabilitation. |
Occupational Therapy |
Individualized occupatonal therapy services at a convenient clinic that is focused on return to work goals through physical conditoning and job simulation tasks. This is appropriate when the injured worker does not have an option to perform transitional work. |
Work Conditioning Program |
An individualized therapy program
that is focused on regaining optimal function and return
to work goals through physical conditioning and job
simulation tasks. This is appropriate when the injured
worker does not have an option to perform transitional
work. |
Ergonomic
Accommodation Study (W0644) |
Ergonomic analysis of how a worker's restrictions impact safe job performance, with
recommendations for temporary or permanent job modifications. |
Functional
Capacity Evaluation |
A comprehensive
evaluation of physical disability to determine permanent restrictions
and facilitate job search or settlement. |
Workability Case Review |
Review of medical records to
determine appropriateness of diagnosed conditions
related to the claim and facilitate appropriate
treatment or return to work release. |
Workability Independent Medical Exam |
A multidisciplinary evaluation by therapy, medical or vocational experts to address such issues as MMI, impairment, extent of disability, need for further health care,
impact on employability, or eligibility for disability benefits.
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Name |
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Claim Number |
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Address (Street, City, State, Zip) |
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Phone Number |
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Company Location | |
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Company Name |
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Work Location (Street, City,
State, Zip) |
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Contact Name |
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Phone Number |
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Email Address |
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Attending Physician Information
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Name |
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Practice Name |
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Mailing Address (Street, City, State, Zip) |
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Phone Number |
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Fax Number |
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Referral Source Information | |
Name |
* * |
Company |
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Phone Number |
* * | |
E-mail Address |
* * A referral confirmation will be e-mailed
to this address | |
Fax Number |
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Send Bill To: |
Payer Name |
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Address (Street, City,
State, Zip) |
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Phone Number |
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Fax Number |
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