PRS

Ereferral Form

Please complete this form to fill requirements for medical therapy staffing for your home care patient.

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eReferral Types

Therapy

Nursing

Ereferral base on EInquiry

Enter Inquiry Id *

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REFERRING AGENCY DETAILS

Please provide details on the referring company below.

Do you have a preferred clinician that you want to service your patient?

NO - Please assign qualified clinicans based upon the needs of my patient.

YES - I have a preferred clinican and I will provied the name in comments section below.

YES - I have previously provided SSS with a specifici list of clincians that can service our patients.

Client Company Name *

Select Client Company Name

Note If you are not getting your agency name then contact administrative.

Client Contact Name *

First Name

Last Name

Client Contact Email *

Please provide email where confirmation of referral may be sent.

PATIENT DETAILS

Please provide patient details below.

Patient Name *

First Name

Last Name

Patient Date of Birth

MM/DD/YYYY

Patient Type *

What is the Patient's age? *

Patient Age

Patient Gender *

Patient Address *

Street Address

City

State / Province / Region

Postal / Zip Code

Country

Patient Primary Phone *

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Referring Physician Name *

First Name

Last Name

Referring Physician Phone

Referring Physician Fax

MANAGED CARE DETAILS

Primary/Secondary Diagnosis AND/OR Therapy Diagnosis *

Approved Number of Visits *

Authorization Start Date

MM/DD/YYYY

Authorization End Date

MM/DD/YYYY

Certification Period Start Date *

MM/DD/YYYY

Certification Period End Date *

MM/DD/YYYY

REQUESTED DISCIPLINE DETAILS

PHYSICAL (PT/PTA) *

Select file Change

Upload File PHYSICAL (PT/PTA)

OCCUPATIONAL (OT/COTA) *

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Upload File OCCUPATIONAL (OT/COTA)

SPEECH (SLP/SLPA) *

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Upload File SPEECH (SLP/SLPA)

SOCIAL WORKER (LCSW/MSW) *

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Upload File SOCIAL WORKER (LCSW/MSW)

NURSE (RN/LVN) *

What type of skilled nursing?

HOME HEALTH AIDE (CNA) *

SKILLED NURSING visit frequency ?

HOME HEALTH AIDE visit frequency ?

Timing of Evaluation ?

Gender Preference ?

Which type of attachment is uploaded? *

485

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History & Physicals

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Orders

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Last Visit Note

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Evaluation

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Others

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Language Pref ?

Additional Information/ Special Instructions