NYU Rusk Institute Outpatient Referral Form
This form is designed for patients seeking outpatient multidisciplinary care at NYU Rusk Institute. It facilitates necessary patient information for effective treatment coordination. Users should fill in personal details, insurance information, and diagnosis.
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How do I fill this out?
To fill out this form, gather the patient's personal and insurance information. Ensure that a diagnosis is selected from the provided options. Complete the physician's details and obtain the necessary signature.
How to fill out the NYU Rusk Institute Outpatient Referral Form?
1
Gather patient information including name, date of birth, and address.
2
Fill in insurance details, including policy numbers and insured names.
3
Select the required diagnoses for therapy services from the list.
4
Complete the physician's information and signature.
5
Submit the form via fax or the designated method.
Who needs the NYU Rusk Institute Outpatient Referral Form?
1
Patients seeking physical rehabilitation services.
2
Healthcare providers referring a patient to outpatient therapy.
3
Insurance representatives requiring patient information for claims.
4
Administrative staff coordinating patient appointments.
5
Family members assisting patients with the referral process.
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What are the instructions for submitting this form?
To submit this form, please fax it to the NYU Rusk Business Office at (212) 263-0113. Ensure that all fields are completed accurately to avoid delays. Alternatively, you may contact the office for additional submission methods.
What are the important dates for this form in 2024 and 2025?
Important dates for this form in 2024 and 2025 include submission deadlines for insurance approval and scheduled appointment timelines. Ensure to check with the Rusk Institute for specific date requirements related to therapy sessions. Timely submission is crucial for effective patient care.
What is the purpose of this form?
This form serves as a vital tool for patients who require coordination of their rehabilitation care. By providing necessary personal and medical information, it ensures healthcare providers have all details for effective treatment planning. Ultimately, it facilitates seamless communication between patients and medical professionals.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient.
- 2. Patient Date of Birth: The birth date of the patient.
- 3. Patient Social Security Number: The social security number for identification purposes.
- 4. Insurance Information: Details related to the patient's insurance provider.
- 5. Diagnosis: The medical diagnosis required for treatment.
- 6. Physician's Name/Specialty: The name and specialty of the referring physician.
What happens if I fail to submit this form?
Failing to submit this form may lead to delays in obtaining necessary medical services. Without proper documentation, appointments may be postponed or canceled. It's critical to ensure that all fields are completed accurately before submission.
- Delayed Treatment: Patients may experience delays in receiving necessary therapies.
- Insurance Issues: Incomplete forms can lead to complications with insurance reimbursements.
- Appointment Cancellations: Missing submissions can result in canceled or postponed appointments.
How do I know when to use this form?
- 1. Outpatient Physical Therapy: Use this form when referring a patient for outpatient physical therapy sessions.
- 2. Occupational Therapy Referral: This form is necessary for occupational therapy referrals as well.
- 3. Speech Therapy Requests: When requesting speech and language pathology services, this form is required.
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