Patient Demographic Information
*Check all that apply to the patient
Intermittent Explosive Disorder
History of violence
Cardiac anomolies i.e. arrythmia, hypertension
By clicking the check box below, you acknowledge that patients seeking Physical Therapy, Occupational Therapy and/or Speech-Language Pathology must be seen in BSNS’ clinic, unless there is evidence of medical necessity. If the patient is to be seen in their residential home or Day Habilitation program and there is NO evidence of medical necessity, BSNS charges an additional trip fee of 25% of the contracted rate for each visit. BSNS will contact the provider before rendering in-home services.
By clicking the check box below, you acknowledge that a minimum of three (3) hours must be on the Individual Plan of Care (IPC) for all Home & Community Based Services (HCS) at the time the referral is submitted.
By clicking the check box below, you acknowledge that evaluations are only good for 60 days. If treatment is not approved within that time frame a new evaluation will need to be completed at the expense of the provider.