ONLINE REFERRALS – Fitco Healthcare

Online Referral Form

Please complete this Online Referral Form so that our team has your permission to contact the case manager (insurer) managing your injury claim, to discuss your injury rehabilitation needs and seek approval of fees to facilitate your exercise physiology treatment.

Referrer Details:
What best describes you?
- I'm a Patient
- I'm a Doctor
- I'm an Insurer
- I'm a Rehab Consultant
- I'm an Employer
Patient Details:
Name*
First Last
- Phone*
- Email Address*
Address
Street Address City State / Province / Region ZIP / Postal Code
Birthdate
MM slash DD slash YYYY
Injury Details:
Date of Injury
MM slash DD slash YYYY
Nature of Injury
Service Requested
- Treatment Type
- Delivery Type
Medical Certification
Fitness for Work
Insurance Company
Claim Number
Claim Number*
Case Manager
Case Manager Phone
Case Manager Email
Doctor Details
Doctor's Name
First
Address
Street Address
Phone
Email
Rehab Provider Details:
Consultant Name:
First
Company Name:
First
Phone
Email

Please Note

To ensure that your referral hasn’t disappeared into cyber space, please contact us within 1-2 business days if we have not confirmed receipt of your referral. We will endeavor to obtain approval as soon as possible.

Online Referral Form

Referrer Details:

Patient Details:

Injury Details:

Service Requested

Medical Certification

Claim Number

Doctor Details

Rehab Provider Details:

Please Note