J-13 Covered Conditions Referral Form.pdf

WORLD TRADE CENTER MEDICAL MONITORING & TREATMENT PROGRAM

COVERED CONDITIONS REFERRAL FORM

WTC PROVIDER

Printed Name of Provider:

Office Telephone Number:

Fax Number:

PATIENT INFORMATION GENDER: MALE FEMALE

Patient Name (First/MI/Last):

Date of Birth (mm/dd/yyyy):

Patient WTC Number:

Street Address:

City:

State:

Zip Code:

Home Telephone Number:

Work Telephone Number:

Cell Telephone Number:

REFERRAL TYPE

Physical Health Mental Health Social Work

Internal Medicine Occupational Medicine Pulmonology

ENT

GI

Physiatry Neurology

Orthopedics Pain Management Cardiology Physical Therapy Occupational Therapy Other (Specify)_____________

Psychiatry Psychology SW- Psychotherapy Other (Specify) ______________

Physical Health Benefits Counseling Mental Health Benefits Counseling Other Benefits Counseling Social Work Assessment & Intervention

DIAGNOSIS CODES (Refer to ICD9 List for additional codes) Upper Airway

472.0 Chronic Rhinitis

473.9 Chronic Sinusitis

476.0 Chronic Laryngitis

478.0 Nasal Hypertrophy

Other___.__ Other___.__

Lower Airway

493.90 Asthma, Unspecified

491.20 COPD

491.0 Chronic Bronchitis

786.5 Chest Pain

Other___.__

Mental Health

305.00 Alcohol Abuse

308.9 Acute Stress Disorder

309.91 PTSD

311 Depression NOS Other___.__

Gastrointestinal

530.81 GERD

Musculoskeletal

354.0 Carpal Tunnel Syndrome

723.4 Cervical Radiculitis

724.2 Low Back Pain

726.10 Rotator Cuff Syndrome

Other___.__ Other___.__ Other___.__

Requested Urgency: Emergent (Patient to ER) Urgent Within 1-2 weeks Next available appointment

WTC PROVIDER’S SIGNATURE

WTC Provider Signature:

WTC Provider Number:

Date: ___/___/_____ dd/mm/yyyy

WTC Covered Conditions 1