Houston Occupational Therapy P.L.L.C.

Referral PIN


Referral PIN is provided by our office. Contact us at (281) 759-6644 for more information.

Patient Information

Last Name


First Name & MI


Medicare Number


Date of Birth


Gender

Patient Address

Address


City


State


Zip Code


Phone Number


Please indicate all disciplines in plan of care:


HOT does not provide PT services; PT visits must be arranged with a separate therapy company

Emergency Contact

Contact Name


Contact Phone Number


Referral Details

Hospital Admission Date


Hospital Discharge Date


Diagnosis


Referral Source


Include referring agency/organization, a contact name, and a telephone number for follow-up

Orders


Medications


Certification Period


Include certification beginning and ending dates

Total Number Authorized Visits


Include certification of authorized OT visits, including evaluation

Additional Notes


Include a key map, or any other relevant information regarding orders, patient concerns, or scheduling