UMRH
United Medical Physical Rehabilitation Hospital
New Orleans Campus
3201 Wall Blvd, Suite B
Gretna, LA 70056
📠FAX COMPLETED FORM TO: 504-433-5551
INPATIENT REHABILITATION REFERRAL FORM
PATIENT INFORMATION
Patient Name (Last, First, MI)
Date of Birth
Social Security # (Last 4)
Phone Number
Gender
Address
INSURANCE INFORMATION
Primary Insurance
Policy/Member ID
Secondary Insurance (if applicable)
Policy/Member ID
CLINICAL INFORMATION
Primary Diagnosis / Reason for Referral
Referring Hospital
Admission Date
Qualifying Condition (Check all that apply):
Stroke
Brain Injury
Spinal Cord Injury
Hip Fracture
Joint Replacement
Amputation
Neurological
Multiple Trauma
Debility/Weakness
Cardiac
Burns
Other: ________
REFERRING PROVIDER / CASE MANAGER
Name
Phone
Fax
Email
Signature
Date