Rise Physical Therapy Patient Referral Form
Thank you for referring your patient to Rise Physical Therapy. Please complete the form below to submit your referral. Our team will contact the patient within one business day to schedule their evaluation. If you need to reach us directly, call us at (479) 442-7473 or email info@riseptnwa.com.
Locations: East Fayetteville · West Fayetteville · Springdale · Rogers · Bentonville
HIPAA Authorization
By submitting this form, you confirm that you are authorized to share the patient's protected health information (PHI) with Rise Physical Therapy NWA for the purpose of coordinating physical therapy care. Rise Physical Therapy NWA maintains a Business Associate Agreement and handles all patient information in compliance with HIPAA regulations.
Patient Name
*
Patient Date of Birth
*
Patient Phone Number
*
Patient Email
*
Reason for referral
*
Referring Provider Name
*
Preferred Rise Clinic Location
East Fayetteville
West Fayetteville
Springdale
Rogers
Bentonville
Patient Insurance Carrier
Patient Insurance Member ID
I confirm that I am authorized to submit this referral and share the patient's health information with Rise Physical Therapy NWA.
*
Yes
Submit
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