PT Authorization Request

Initial RequestFollow Up Request

Requesting Facility Information (Please fill out the form completely)

Treating Facility Name

Facility Contact

Phone

Fax

State

Injured Party Information

First Name

Last Name

Date of Accident

Date of Birth

Phone

Cell Phone

Address

City

State

Zip Code

Recommended Therapy Information

Date of Initial Visit

Next Appt. Date

Recommended # of Visits

Attorney Information

Firm Name

Contact at Firm

Phone

Fax

State

Please upload the signed physician referral form here, or fax to: 702-463-4259

Questions? Call us at (877) 362-6077