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Providian Amerisys Referrals
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Referral / Authorization Form
Please note: Fields with asterisks (*) need to be completed.

NOTE: For AmeriSys online referrals please click here

      Reimbursement Type:
Please check one or more of the Reimbursement Types you require:

PT ERGO Assessment
FCE Additional PT/OT
OT Impairment Rating
WC    

*Date

Insurance Company Information
*Insurance Company *Name Of Referral Person If Not CM or Adj
*Referral Person Phone
w/ Extension 		    *Fax
*Billing Address  
*City *State *Zip
Adjuster Email    
Adjuster Phone
w/Extension 		    Fax
Case Manager Email    
Case Manager Phone
w/Extension 		    Fax
Patient Information
*Patient Name: Last *First *Home Phone
*Address *Work Phone
*City *State *Zip
*Patient Birthdate *Social Security *Date of Injury
Work Status




*Claim #
Occupation
Special Instructions
Physician Information
*Physician First Name *Last Name    
*Physician Phone *Fax    
*Diagnosis    
*Number of
PT Visits		 Script: Call MD to obtain RX   Patient has copy
Attorney Information
Attorney Represented Yes     No          Not known at this time
Claimant Attorney Name Phone Fax
Defense Attorney Name Phone Fax
*Employer Phone Fax
Address  
City State Zip
 
 


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The Leading Provider of Physical Therapy, Functional Capacity Evaluations,
Work Conditioning, and Ergonomic Analysis NATIONWIDE.

Physical Therapy Nationwide 888-957-3337, fax 877-636-7389, providianpt@comcast.net

FCEs in Georgia 888-557-0557, fax 423-485-1499, providianpt3@comcast.net

FCEs in Florida 888-880-3237, fax 904-819-5522, fcereferral@comcast.net

The Right Path to Return To Work Faster Nationwide

www.ProvidianFCS.com

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