NEW PATIENT INFORMATION

BEFORE YOU BEGIN FILLING OUT THE FORM BELOW, MAKE SURE THAT YOU HAVE ADOBE READER ON YOUR COMPUTER, OR THE FORM WILL NOT WORK CORRECTLY.

How can I get my child in to be seen?

For families seeking Occupational and/or Physical Therapy Services for their children we need the following:

1. A prescription/written referral.

You will need to obtain a prescription from your child’s physician for the evaluation and/or therapy services. Please contact the doctor directly to request the prescription to be faxed to our office at 541-770-9212. The prescription will need to include the following:

  • The diagnosis code. (ICD10 code)
  • The frequency and duration of recommended visits. (i.e. 1-2 times weekly for 12 months).

If it doesn’t include the above we will be unable to proceed further as insurance will reject it and reject any request for visits.

2. Fill out and return our New Patient Packet

Please select from the options below to download a New Patient Packet. These are fill-able forms which, after being downloaded, can be completed, saved and emailed back to our confidential email at MCT@nt4kids.org.

*In order for the information to enter in correctly and to save your progress on a form, you will need to have an up-to-date version of Adobe Reader on your computer.

New Client Packet OT & PT
(Please note. When you first click on the link it will open in a new tab in your browser. DO NOT FILL IT OUT HERE. You need to download our packet to your desktop and then fill it out there)

These forms can also be downloaded, printed and then the completed form can be faxed or mailed to our office at 400 Crater Lake Avenue, Medford, OR 97504

VERY IMPORTANT!

If we are billing your insurance company, you must contact your insurance company for benefit and coverage information so you are aware of what will be covered.

Once we receive your completed paperwork and the prescription from your doctor, our scheduler will contact you to schedule an appointment for the initial evaluation.