Oncology Referral/Physician Form (pdf) - Centegra Health System

Patient Name:Centegra STAR PROGRAM®Oncology Referral / Physician Order_____________________________________________DOB:_____________________________Fax completed and signed form to Centegra STAR Program Coordinator: 815-759-4875If you need to reach the Centegra STAR Program Coordinator please call: 815-759-4870PATIENT INFORMATIONAddress: Check if English is not the primarylanguage and a translator is needed.Day Time Phone:Cell Phone:E-mail:Cancer Diagnosis & Date of Onset:Special Precautions and/or Contraindications:Rehab Diagnosis:Duration & Frequency:REFERRAL FOR ONCOLOGY PATIENTS TO CENTEGRA STAR PROGRAM Physiatry ConsultationOutpatient Therapy Services Physical Therapy Evaluation & Treatment Occupational Therapy Evaluation & Treatment Speech Language Cognitive Evaluation & Treatment Video Swallow Evaluation Swallow Evaluation & Treatment Lymphedema Evaluation &Treatment Pelvic Floor Evaluation & Treatment Vestibular Evaluation & Treatment AquatherapyHome Health Services Physical Therapy Evaluation & Treatment Occupational Therapy Evaluation & Treatment Speech Therapy Evaluation & Treatment NursingBack to Work Ergonomic Evaluation Functional Capacity Evaluation Work Conditioning Work HardeningOther Services Nutritional Counseling Education Visit Smoking Cessation Wound Care & Hyperbaric Services Psychosocial Support Services Pastoral Care Centegra WellBridge Program Palliative Care Financial/Medication Assistance Other: ____________________________________________________________________________________I certify that these services are medically necessary.Name of Referring Physician (please print)__________________________________________Signature of Referring Physician_____________________________________________Phone#: ______________________________Fax#: ______________________________ Date: ______________________________C9620245 10-2013

Common Oncology Rehab DiagnosesNeck & Back Disorders353.2 Cervical root lesions, not elsewhere classified724.1 Pain in thoracic spine724.2 Lumbago353.1 Lumbosacral plexus lesions353.4 Lumbosacral root lesions, not elsewhere classified336.3 Myelopathy in other diseases, classified elsewhere723.1 Cervicalgia336.8 Other myelopathy353.8 Other nerve root and plexus disorders733.00 Osteoporosis, unspecified719.40 Pain in joint, site unspecifiedUpper Extremity353.0 Brachial plexus lesions718.49 Contracture of joint of multiple sites719.43 Pain in joint, forearm719.44 Pain in joint, hand719.42 Pain in joint, upper arm719.41 Pain in joint, shoulder region719.50 Stiffness of joint, not elsewhere classified,unspecified siteLower Extremity719.47 Pain in joint, ankle and foot718.49 Contracture of joint of multiple sites719.45 Pain in joint, pelvic region and thigh719.46 Pain in joint, lower legPelvic Floor Disorders788.39 Other urinary incontinence788.33 Mixed incontinence, (male) (female)788.43 Nocturia618.83 Pelvic muscle wasting625.9 Unspecified symptom associated with femalegenital organs625.6 Stress incontinence, female788.32 Stress incontinence, male788.31 Urge incontinence788.41 Urinary frequency788.30 Urinary incontinence, unspecified564.00 Constipation, unspecified787.60 Full incontinence of feces728.9 Unspecified disorder of muscle, ligament and fascia709.2 Scar conditions and fibrosis of skinGait and Coordination781.2 Abnormality of gait334.4 Cerebellar ataxia in diseases, classifiedelsewhere719.7 Difficulty in walking781.3 Lack of coordination728.9 Unspecified disorder of muscle, ligamentand fascia334.3 Other cerebellar ataxiaSpeech/Swallowing Disorders438.11 Aphasia438.81 Apraxia784.51 Dysarthria (speech disturbance), excludeslate effects of cerebrovascular disease438.13 Dysarthria, late effects of cerebrovasculardisease438.82 Dysphagia787.20 Dysphagia, unspecified784.92 Jaw pain787.29 Other dysphagia438.10 Speech and language deficit, unspecifiedV41.6 Problems with swallowing and masticationCognitive Disorders438.0 Cognitive deficits799.52 Cognitive communication deficitFatigue780.71 Chronic fatigue syndrome780.79 Other malaise and fatigueOther Neurological Disorders436 Acute, but ill-defined, cerebrovasculardisease342.80 Other specified hemiplegia affectingunspecified side438.20 Hemiplegia affecting unspecified side344.9 Paralysis, unspecifiedAdditional Diagnoses & Codes357.6 Polyneuropathy due to drugs909.2 Late effect of radiationLymphedema457.1 Other lymphedema457.0 Postmastectomy lymphedema syndrome709.2 Scar conditions and fibrosis of skin