Providian FCS Functional Capacity Evaluations Referral/Amerisys Authorization Form

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

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