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Submit a Referral

For referring physicians, adjusters, case managers and other referral sources. Our scheduling department contacts the patient within one business day.

1. Who is sending this referral? *

So our team can confirm the referral with you. Your reference number appears on screen when you submit.

2. Case type *

This decides which fields you see next. You will only be shown the section that applies.

3. Patient information

So we can arrange interpretation before the visit.

Last 4 of SSN — only if your carrier requires it
4. Case details
Choose a case type in step 2 above. The fields for that case will appear here.
5. Attachments

Form NF-2, Form C-3, police report, insurance card, letter of protection, referral letter, prior imaging or reports. PDF, JPG or PNG.

Up to 10 files and 20 MB in total. Larger packets can be faxed to (877) 992-0798. Files are encrypted in transit and at rest.

HIPAA authorization

By submitting this form, you confirm that you are authorized to share this information and that the patient authorizes the release and use of relevant medical, insurance and claim information for the purposes of appointment scheduling, referral processing, insurance verification, treatment coordination and related medical office administrative functions.

You will receive a reference number immediately and a scheduling confirmation within one business day.
Questions? referrals@motionorthopedics.com  ·  Secure fax (877) 992-0798

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