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2371090476250Helping people challenged by disabilities, vision loss or aging live vital lives.00Helping people challenged by disabilities, vision loss or aging live vital lives.28575-87630000right-529730Fax to: (218) 624-4479Or mail to: 4505 W Superior StDuluth MN 55807Phone: (218) 624-482800Fax to: (218) 624-4479Or mail to: 4505 W Superior StDuluth MN 55807Phone: (218) 624-4828 Occupational Therapy ReferralPatient Name:DOB:Referral Date:Address:City:State:Zip:Patient Phone:Other contact if needed:Reason for referral/please describe patient therapy needs as you know them:Orders (please check all that apply)? Occupational Therapy Evaluation and Treatment (For Low Vision and/or Other Functional Challenges. Services can help with home safety and clients’ ability to perform activities of daily living, as well as leisure or employment tasks. OT services can also address access to technologies to improve well-being.) ? Other Services (Circle those of interest) (Assistive technology, support group, family education, orientation and mobility training, Lighthouse store for adaptive devices, or Device loans or demonstrations)If available, please send the last comprehensive eye exam (dilated exam) and Visual Field as well as complete the following:Diagnoses (ICD 10 codes if known):ICD 10 Impairment Code(s)/Treatment Diagnosis (if known): (low vision OD/OS/OU, field deficits, scotoma(s), glare sensitivity, or other functional deficits related to other conditions)Visual Acuity (with best correction)OD:OS:OU:Write in doctor’s name or place label below.Doctor’s Name:Practice Name:Address:Phone No.Signature:Fax No.This form is available for download at referral ................
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