Rehabilitation Referral Information
Physical therapy, occupational therapy, speech language pathology
For patient information, please visit the specialty page.Rehabilitation Referral Contact Information:
Process for authorization and required documents will differ depending on payer. DCH will initiate authorization whenever possible.
Referring Physicians Must Fax the Following Information:
- DCH patient referral form or physician’s order including physician’s signature
- Discipline ordered
- Evaluation and/or treatment specified
- Diagnosis, including ICD-10, supporting service requested The etiological reason for a functional delay/disorder should be included among the diagnoses listed, if not present, services may be denied by payer.
- Demographic information or face sheet if not on the order
- Physician’s notes or H&P supporting requested services
- Insurance / Medicaid card (front and back)
- If order for Speech Language Pathology, please indicate type of evaluation and/or treatment and ensure related diagnosis:
- Speech and language evaluation/treatment
- Feeding evaluation/treatment
- Video fluoroscopic swallow study/treatment
- Payer may require developmental screening documentation.
- Payer may require hearing screening or hearing testing results. Please indicate if speech and language evaluation is pending audiology results.
Note: The DCH Orthopedic Clinic staff will contact the referring physician’s office after all information is received and reviewed.
Patients Must Bring the Following to Appointment:
- List of current medications
- If the patient receives a questionnaire in the mail, complete and bring to appointment
- Patient must be accompanied to appointment by parent or guardian
