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

   
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.

 
Name

 
Claim Number

 
Address (Street, City, State, Zip)

 
Phone Number

 

Company Location

   
Company Name

 
Work Location (Street, City, State, Zip)

 
Contact Name

 
Phone Number

 
Email Address

 

Attending Physician Information

 
Name

 
Practice Name

 
Mailing Address (Street, City, State, Zip)

 
Phone Number

 
Fax Number

 

Referral Source Information

 
Name *
Company
Phone Number

*

 
E-mail Address

*
A referral confirmation will be e-mailed to this address

 
Fax Number

 

Send Bill To:

Payer Name
Address (Street, City, State, Zip)

Phone Number

Fax Number

   

 
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