Outpatient Rehabilitation Request for Services This is not an insurance referral.

Patient Name: ______Date of Birth: ______/ ______/______Day/Work Phone: ______Cell Phone: ______Diagnosis:______Goals/Comments/Special Instructions: ______Follow-up Visit (with referring physician) ______/______/______

I certify the necessity of this treatment ➧ Physician Signature______/(Print)______Date:______NPI #______Attending Physician Name (print clearly) ______Tax ID #______Office Phone: ______Fax:______Email (if preferred contact method):______

PHYSICAL THERAPY OCCUPATIONAL THERAPY PM&R SERVICES (PHYSICIAN) c EVALUATE & TREAT ŀ c EVALUATE & TREAT ŀ c Bethesda c Friendship Heights c c c Irving Street c MedStar Montgomery Aquatic Therapy ADL/Self-Care c c Back Education & Back School c Assistive/Adaptive Equipment MedStar Medical Center Georgetown c McLean c Biofeedback c Cognitive Skills Training University c Electrical Stimulation/TENS c Electrical Stimulation c Energy Conservation c Energy Conservation/Joint Protection c c c c Treatment Consultation Falls Prevention Functional Mobility c Cancer/Oncology Rehabilitation c c Flexibility Hand Therapy (see separate category) c EMG/Nerve Conduction c c Functional Mobility Vision: Evaluate & Treat c Fluoroscopic Injection (Bethesda, Irving c c Gait Training Manual Therapy Street and Georgetown locations) c Home Exercise Program c Neuro Re-education c Geriatric Rehabilitation c Manual Therapy c Perceptual Motor Skills Training c Independent Medical Evaluation (IME) c Posture Training c Strengthening c ROM c Dexterity c Joint/Trigger Point Injection c Orthotics/Prosthetics c Splinting/Orthotic Fabrication/Training c Osteopathic Manipulation (Bethesda, c Orthotic Fabrication c Work/Community Skills Irving St) c Stabilization: Lumbar/Cervico-Thoracic c Other: ______c Pain Management c Strengthening c ROM c Neurological Disorders c c Traction: Cervical/Lumbar SPEECH/LANGUAGE PATHOLOGY Second Opinion c c Ultrasound/Phonophoresis Workers’ Comp Evaluation & Treatment c EVALUATE & TREAT ŀ c Vestibular/Balance Training c c Language/Communication OCCUPATIONAL REHABILITATION (PT/OT) Other: ______c Cognitive — Communication Treatment c Back Education & Training c Dysphagia/Swallowing c SPECIAL SERVICES (PT/OT)** Functional Capacity Evaluation (FCE) c LSVT LOUD for Movement Disorders c Work Conditioning c EVALUATE & TREAT ŀ c Voice c Worksite Evaluation/Ergonomic Analysis c c c Breast Cancer Rehabilitation Voice Training Services Other:______c Continence Program (bladder, bowel) c Augmentative/Alternative Communication ADDITIONAL PROGRAMS c Facial Palsy c Articulation (Pediatrics) c LSVT BIG (PT/OT) for Movement Disorders c Accent Modification c Acupuncture** c Lymphedema Management c Patient/Family Education & Training c Aphasia Clinic (MD, SLP)* c Upper c Lower c Other: ______c Baclofen Pump Maintenance/Refills* c c Pelvic Pain Rehabilitation Cerebral Palsy Interdisciplinary Clinic* c c Other: ______PSYCHOLOGY Chronic Pain Management** (MD, Psy) c Driving Evaluation (PT/OT/RE)* c Behavioral Medicine And Pain Evaluations c Dry Needling** HAND THERAPY (PT/OT) c Neuropsychological Evaluations c Fibromyalgia Management c c EVALUATE & TREAT ŀ Relaxation Training/Stress Management c Foot & Running Clinic** c c c Splinting Sleep Hygiene Counseling Modified Barium Swallow* c c c dynamic c static Therapy And Counseling For Adjustment Neurological/Stroke, TBI, SCI Day Treatment c c c to Illness/Injury And Pain Program* (PT, OT, SLP, Psy) forearm hand finger c c c c Other: ______Post-Polio Clinic* (PT, OT, SW, MD) flexion extension c Rehab Engineering Assistive Technology* c ROM (Range of Motion) c SCI Fertility Clinic* c c c AROM AAROM PROM c Seating/Mobility/Wheelchair Clinic (PT/OT)** c Strengthening c Spasticity Clinic (Botox Injections)* (MD) c Other: ______c Spinal Cord Injury Day Treatment Program* c Vocational Rehabilitation* c Other:______

Please contact your insurance company to determine your plan’s specific referral requirements. *Irving Street/Main Hospital outpatient location only. **Services only offered at limited locations; please call location nearest you for assistance to find where offered.

0115 MedStarNRH.org WASHINGTON, DC MedStar NRH Rehabilitation Network Carroll County Oxon Hill MedStar NRH Rehabilitation Network 301-839-0400 301-839-0130 FAX MedStar NRH Rehabilitation Network Irving Street Westminster Southern Maryland 410-751-7930 410-751-7931 FAX Physical and Occupational Therapy 202-877-1760 202-829-2789 FAX NRH Rehabilitation Network City Speech/SLP, Dietary, Psychology, Vocational Hollywood** 301-373-2588 301-373-4558 FAX MedStar NRH Rehabilitation Network Rehab, Rehab Engineering Federal Hill 202-877-1440 202-291-2836 FAX NRH Rehabilitation Network 410-230-7830 410-230-7831 FAX Outpatient Center for Orthopaedic Rehab Waldorf** MedStar NRH Rehabilitation Network (OCOR) 301-893-2345 301-638-1783 FAX MedStar Good Samaritan Hospital A part of MedStar NRH Rehabilitation Network NRH Rehabilitation Network 443-444-5757 443-444-5750 FAX 202-877-1566 202-877-1113 FAX Waldorf Pembrooke Square MedStar NRH Rehabilitation Network MedStar NRH Rehabilitation Network 301-719-1146 301-645-5343 FAX Stadium Place OCOR Hand Clinic Montgomery County 410-366-0791 410-366-0930 FAX 202-877-3322 202-204-5821 FAX MedStar Union Memorial Hospital NRH Rehabilitation Network NRH Rehabilitation Network Rehabilitation & Sports Medicine Bethesda* K Street, NW* 410-554-2318 410-554-2316 FAX 301-581-8030 301-581-8031 FAX 202-466-9719 202-466-9465 FAX MedStar NRH Rehabilitation Network MedStar NRH Rehabilitation Network NRH Rehabilitation Network MedStar Harbor Hospital Sports Medicine Chevy Chase 19th Street, NW* 410-350-8372 410-350-3821 FAX 301-951-0546 301-215-4488 FAX 202-721-7680 202-955-7998 FAX MedStar NRH Rehabilitation Network NRH Rehabilitation Network Wilkens Avenue VIRGINIA Friendship Heights* 410-737-8418 410-536-7127 FAX 301-986-4745 301-657-4678 FAX MedStar NRH Rehabilitation Network Baltimore County Alexandria NRH Rehabilitation Network MedStar NRH Rehabilitation Network 703-647-3110 703-822-9955 FAX Germantown* Dundalk 301-916-8500 301-528-6258 FAX MedStar NRH Rehabilitation Network 410-650-2145 410-282-5955 FAX Ballston MedStar NRH Rehabilitation Network MedStar NRH Rehabilitation Network 703-717-6900 703-717-6909 FAX Leisure World Blvd. Dundalk-Northpoint 301-438-6280 301-438-6281 FAX 410-282-2244 410-288-7983 FAX MedStar NRH Rehabilitation Network Available to residents of Leisure World only. Marymount MedStar NRH Rehabilitation Network 703-292-4060 703-292-4066 FAX NRH Rehabilitation Network Perry Hall Montrose* 443-725-2150 443-725-2155 FAX MedStar NRH Rehabilitation Network Lake 301-984-6594 301-984-7271 FAX Ridge MedStar NRH Rehabilitation Network 703-647-3130 703-490-6505 FAX NRH Rehabilitation Network Lutherville Hand Center Olney*** 410-823-4263 410-823-1861 FAX MedStar NRH Rehabilitation Network 301-570-3138 301-570-3139 FAX MedStar NRH Rehabilitation Network Lorton Lutherville Sports Medicine 703-647-3120 703-339-6352 FAX NRH Rehabilitation Network 410-512-5820 410-512-5859 FAX Wheaton* MedStar NRH Rehabilitation Network 301-962-7612 301-962-7782 FAX MedStar NRH Rehabilitation Network McLean White Marsh 703-288-8260 703-288-9316 FAX Anne Arundel County 410-282-2255 410-238-1581 FAX MARYLAND MedStar NRH Rehabilitation Network Pasadena DELMARVA Prince George’s County 410-590-8750 410-590-8755 FAX Peninsula/NRH Rehabilitation Network Millsboro† MedStar NRH Rehabilitation Network Harford County Clinton 302-934-1783 302-934-1792 FAX 301-719-1140 301-856-8215 FAX MedStar NRH Rehabilitation Network Peninsula/NRH Rehabilitation Network Bel Air Salisbury† MedStar NRH Rehabilitation Network 410-638-9400 410-638-9061 FAX Mitchellville 410-546-2702 410-546-8272 FAX 301-390-3076 301-390-3725 FAX Howard County MedStar NRH Rehabilitation Network Ellicott City 410-997-1063 410-997-1408 FAX

The NRH Rehabilitation Network is a growing network of outpatient therapy centers located throughout Maryland, the District of Columbia and Northern Virginia. It is a part of MedStar National Rehabilitation Hospital (MedStar NRH). A number of centers are a joint service of MedStar NRH and (*); MedStar NRH, Calvert Memorial Hospital, Calvert Physical Therapy and Sports Fitness Center, University of Maryland Charles Regional Medical Center, and MedStar St. Mary’s Hospital (**); MedStar NRH, MedStar Montgomery Hospital Center and Suburban Hospital (***); and MedStar NRH and Peninsula Regional Health System (†)

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