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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
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An objective, post-offer screen of musculoskeletal health and workabilities to promote job safety and productivity.
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Transitional Work Therapy (W0637)
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Therapeutic activities at the work site to accommodate and progress an injured worker with medical restrictions back to productive duty in a targeted job.
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Physical Therapy
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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.
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Occupational Therapy
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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.
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Work Conditioning Program
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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.
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Ergonomic Accommodation Study (W0644)
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Ergonomic analysis of how a worker's restrictions impact safe job performance, with recommendations for temporary or permanent job modifications.
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Functional Capacity Evaluation
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A comprehensive evaluation of physical disability to determine permanent restrictions and facilitate job search or settlement.
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Workability Case Review
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Review of medical records to determine appropriateness of diagnosed conditions related to the claim and facilitate appropriate treatment or return to work release.
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Workability Independent Medical Exam
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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
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Name |
* * |
Company |
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Phone Number |
* *
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E-mail Address |
* *
A referral confirmation will be e-mailed to this address
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Fax Number |
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Send Bill To:
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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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