Rehabilitation Referral Forms for Physicians

A physician’s referral is required for most programs at NYU Langone’s Rusk Rehabilitation. The required forms are listed below:

• Adult General Occupational Therapy
• Assistive Technology: Occupational Therapy
• Barrier-Free Design: Occupational Therapy
• Brain Injury Day Treatment Program
• Breast Cancer
• Cardiac Rehabilitation
• Chest Physical Therapy
• Cochlear Implants
• General Physical Therapy
• Head and Neck Speech–Pathology
• Lymphedema
• Outpatient Adult Multidisciplinary Therapy
• Pelvic Floor Physical Therapy
• Prenatal/Postpartum Physical Therapy
• Psychology
• Pulmonary Rehabilitation
• Speech–Language Pathology
• Vestibular Physical Therapy
• Vision Rehabilitation: Occupational Therapy
• Vocational Rehabilitation

Referral Information for Medical Facilities

To initiate a referral to Rusk Rehabilitation, the patient’s current social worker should review our discharge checklist and use Allscripts or fax to send the appropriate medical records to 212-263-8510. These should include the following:

• face sheet, including demographic and insurance information
• medical history and physical
• active medication list
• most recent lab results from the last 48 hours, including complete blood count and basic metabolic panel; last 3 sets of labs
• diagnostic and imaging reports
• medical consults, such as cardiology, neurology, gastroenterology, ophthalmology, or endocrinology
• notes from the last 72 hours as well as initial notes
• notes from physical therapy, occupational therapy, and speech–language pathology therapy
• most recent progress notes from the primary team
• operating room notes, if applicable
• social work assessment, including information about the patient’s social situation, to allow our team to create a post-rehabilitation plan
• nursing unit phone number
• resident and attending physician phone numbers

After Rusk Rehabilitation’s outreach and admissions team receives this information and the referral, a member of the clinical liaison team contacts the referring social worker, the patient, and if appropriate, the patient’s family. To contact the outreach and admissions team, please call 212-263-6034.