Providian FCS Functional Capacity Evaluations

NOTE: For AmeriSys online referrals please click here

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

*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	Full Time Part Time OOW		*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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FLORIDA Phone: (888) 880-3237 Email: FCEREFERRAL@COMCAST.NET
GEORGIA, NORTH CAROLINA, SOUTH CAROLINA	Phone: (888) 957-3337	Email: PROVIDIANPT@BELLSOUTH.NET