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Request for Order
Please Fax to Dr.Alina @ Full Distance @ 571-363-2753 - A Medicare Part B Provider
Full Distance 100 Retreat Lane, PO Box 378, Huddleston, VA 24104
P: 540-328-1983 F:571-363-2753 W:
fulldistance.com
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Date of Request:
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To:
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Phone:
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Fax:
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Client's Name:
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Client's Phone:
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Client's Date of Birth:
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Type of Service(s) Needed:
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Physical Therapy/ Occupational Therapy
Physical Therapy
Occupational Therapy
Length of Treatment- Number of Weeks:
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Length of Treatment- Number of Days a Week:
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Diagnosis:
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Abnormality of Gait
Muscular Wasting/ Disuse Atrophy
ADL Dysfunction
Pain (specify under other)
Alzheimer's/ Dementia
COPD
Osteoporosis
Lack of Coordination
Debility (Deconditioning)
DJD (specify under other)
Contractures
Parkinson's
W/C Eval. and Inst.
Other:
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Verbal Order on Behalf of (Physician/ Doctor Name):
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Received By:
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Was it Faxed to Referral Source for Signature?
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Physician's Signature (Initials):
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Print Physician's Name:
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Physician's NPI:
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Date:
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