Comprehensive Inpatient Rehabilitation Physician Referral Form Please fill in the required information in the fields below and fax it back to us at (608) 741-6953.
Referral checklist: Patient face sheet with demographic information and insurance coverage Private insurance information Insurance company: _____________________________________________________ Case manager name: _____________________________________________________ Case manager phone number: (_______)_________-_______________________ Name of referring physician: ___________________________________________________ Referring physician phone: (_______)____________-_______________________________ H&P Physiatry consult, if completed One-two days of most recent physician progress notes One-two days of most recent nursing notes One-two days of most recent therapy notes (PT, OT and ST, as applicable) Current lab reports Discharge plan post rehab, if known Name of local primary care physician, if known: _________________________________________ Name of referring social worker/case manager: _________________________________________ Referring social worker/case manager phone number: (_______)_______-_________________
Thank you for your referral. A member of our admission team will be in contact as soon as the information is reviewed. In the meantime, feel free to call us with any questions you may have at (608) 756-6842.