Referral for FlexTogether Virtual Pulmonary Rehab

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Patient's Name *

Patient's Date of Birth *

YYYY

Patient's Telephone Number *

Diagnosis *

ICD-10 code J44.9: Chronic Obstructive Pulmonary Disease, Unspecified

ICD-10 Code J84.9: Interstitial pulmonary disease, Unspecified

ICD-10 Code U09.9: Post COVID-19 condition, unspecified

Other:

Required

Optional: Primary & Secondary Insurance Information (Payer & ID#)

PROVIDER’S ORDERS
Physical Therapy: Evaluation and Therapy

Occupational Therapy: Evaluation and Therapy

Speech Therapy: Evaluation and Therapy

Printed Name of Physician/PA/NP *

Signature *

I agree to this order and acknowledge that this patient does not have any absolute contraindications listed below.

I agree

Required

Absolute Contraindications

Unstable heart condition: unstable angina, arrhythmia, or uncontrolled heart failure, recent acute coronary syndrome.
Unstable bone fracture
Pulmonary hypertension defined by a pulmonary artery pressure greater than 25 mmhg or on any pulmonary hypertension treatments
Severe cognitive impairment that would interfere with participation
Uncontrolled psychiatric disease
Impaired eyesight or hearing that would make participation challenging
Severe uncontrolled anemia

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