Providian FCS Functional Capacity Evaluations Referral/Amerisys Authorization Form

AmeriSys Online Referrals Only

Reimbursement Type (Required) Please type in one or more of the below Reimbursement Types here: FCE, PT, OT, Additional PT/OT, ERGO Assessment, WC, Impairment Rating
Injured Worker's Name *Required
Social Security Number *Required
Date of Injury *Required
Referred by	Case Manager Adjuster (Please check one)
Phone *Required
Email
Fax *Required

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

For Physical Therapy:

Phone: 888-957-3337; Email: providianpt@comcast.net

For FCEs:

Phone: 888-880-3237; Email: fcereferral@comcast.net

The Right Path to Return To Work Faster Nationwide

www.ProvidianFCS.com