Phone: 614-868-1115 Fax: 614-863-9338
Website: RBAtherapy.com
Email: Intake@rbatherapy.com
698 Morrison Road Columbus, Ohio 43213
Patient Name: _________________________________________ DOB: ________________________
Address: ____________________________________________________________________________
Phone #: ________________________________ Email: _____________________________________
DX: ________________________________________________________________________________
Social Security #: _________________________ Responsible Party: ___________________________
Primary Insurance: ________________________ Member ID: ________________________________
Group#; _________________________ Plan: _____________________ Other: _________________
Primary Insurance: ________________________ Member ID: ________________________________
Group#; _________________________ Plan: _____________________ Other: _________________
Contact Person (if other than patient): _____________________________________________________
Relationship: ________________________________ Phone #: _______________________________
Referring Physician Name: __________________________________ NPI: ______________________
Phone #: ____________________ Fax: ____________________ Email: _______________________
______ Physical Therapy to Evaluate and Treat
___ Wheelchair Assessment ___ Balance / Fall Risk ___ Lymphadema
___ Neurological Disorder ___ Cardiopulmonary Disorder ___ Strength Impairment
______ Occupational Therapy to Evaluate and Treat
___ Home Safety/ Modifications ___ Cognitive / Memory Impairment ___ Deconditioning
___ Adaptive Equipment ___ ADL Assessment ___ Caregiver Stress Assessment
______ Speech Therapy to Evaluate and Treat
___ Communication Impairment ___ Swallowing disorder ___ Cognitive Impairment
______ Audiology ENG Testing
Comments: _________________________________________________________________________
Verbal Order Provided By: ________________________________________ Date: _______________
Physician Signature: _____________________________________________ Date: _______________