Get Fit2wrk Referral Form

Filling out the Fit2wrk Referral Form online is an essential step in ensuring that users receive the appropriate support and services related to their injury or health condition. This guide provides detailed instructions to help you complete the form accurately and efficiently, ensuring all necessary information is included.

Follow the steps to fill out the Fit2wrk Referral Form online

1. Press the ‘Get Form’ button to access and open the Fit2wrk Referral Form in your preferred document editor.
2. Enter the referring source details. Specify if the referral is from a treating medical practitioner, employer, insurer on behalf of the employer, or case management/network.
3. Fill in the worker's information, including their full name, social security number (SS#), date of birth, phone number, and claim number. Provide the worker's address, including city, state, and zip code.
4. Complete the injury information section by entering the date of injury, type of injury, and state of injury. Indicate if the worker has had surgery post-injury and provide the date of surgery if applicable.
5. Provide employer details by entering the company name, contact name, phone number, and address, including city and state.
6. Include medical practitioner details such as the practice name, physician’s name, address, phone number, city, state, and fax.
7. Enter the insurer details, including the company name and zip code.
8. Select the appropriate services related to rehabilitation and evaluations, such as certified hand therapy or occupational therapy, and indicate the frequency of these services per week.
9. Obtain the referral’s signature, enter their printed name, duration, and date to finalize the form.
10. Once completed, save the document, download a copy, print it for records, or share it as needed.

Complete your Fit2wrk Referral Form online today to ensure timely processing!