{"id":321,"date":"2022-11-29T01:17:24","date_gmt":"2022-11-29T01:17:24","guid":{"rendered":"https:\/\/maxicaretherapy.com\/dev\/?page_id=321"},"modified":"2022-12-07T16:40:02","modified_gmt":"2022-12-07T16:40:02","slug":"send-referral","status":"publish","type":"page","link":"https:\/\/maxicaretherapy.com\/dev\/send-referral\/","title":{"rendered":"Send Referral"},"content":{"rendered":"<style>#kt-layout-id_357846-fe > .kt-row-column-wrap{align-content:start;}:where(#kt-layout-id_357846-fe > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}#kt-layout-id_357846-fe > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:var( --global-content-width, 1290px );padding-left:var(--global-content-edge-padding);padding-right:var(--global-content-edge-padding);padding-top:var( --global-kb-row-default-top, 25px );padding-bottom:var( --global-kb-row-default-bottom, 25px );padding-top:100px;padding-bottom:100px;grid-template-columns:minmax(0, 1fr);}#kt-layout-id_357846-fe > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){#kt-layout-id_357846-fe > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){#kt-layout-id_357846-fe > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style>\n<div class=\"wp-block-kadence-rowlayout alignnone\"><div id=\"kt-layout-id_357846-fe\" class=\"kt-row-layout-inner kt-layout-id_357846-fe\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-gutter-default kt-v-gutter-default kt-row-valign-top kt-row-layout-equal kt-tab-layout-inherit kt-m-colapse-left-to-right kt-mobile-layout-row kb-theme-content-width\"><style>.kadence-column_863ace-d2 > .kt-inside-inner-col{border-top-width:0px;border-right-width:0px;border-bottom-width:0px;border-left-width:0px;}.kadence-column_863ace-d2 > .kt-inside-inner-col,.kadence-column_863ace-d2 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column_863ace-d2 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column_863ace-d2 > .kt-inside-inner-col{flex-direction:column;}.kadence-column_863ace-d2 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column_863ace-d2 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column_863ace-d2{position:relative;}@media all and (max-width: 1024px){.kadence-column_863ace-d2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column_863ace-d2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column inner-column-1 kadence-column_863ace-d2\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading_afdb7e-6b, .wp-block-kadence-advancedheading.kt-adv-heading_afdb7e-6b[data-kb-block=\"kb-adv-heading_afdb7e-6b\"]{text-align:center;font-size:40px;font-weight:700;font-style:normal;font-family:Oxygen;}.wp-block-kadence-advancedheading.kt-adv-heading_afdb7e-6b mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading_afdb7e-6b[data-kb-block=\"kb-adv-heading_afdb7e-6b\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading_afdb7e-6b img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading_afdb7e-6b[data-kb-block=\"kb-adv-heading_afdb7e-6b\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading_afdb7e-6b wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading_afdb7e-6b\">Send Referral Form<\/h2>\n\n\n\n<div style=\"height:40px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading_69f4b3-60, .wp-block-kadence-advancedheading.kt-adv-heading_69f4b3-60[data-kb-block=\"kb-adv-heading_69f4b3-60\"]{font-size:16px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading_69f4b3-60 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading_69f4b3-60[data-kb-block=\"kb-adv-heading_69f4b3-60\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading_69f4b3-60 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading_69f4b3-60[data-kb-block=\"kb-adv-heading_69f4b3-60\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading_69f4b3-60 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading_69f4b3-60\">Referral &#8211; Download PDF File &amp; Upload Completed PDF File<\/h2>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading_b4ec59-45, .wp-block-kadence-advancedheading.kt-adv-heading_b4ec59-45[data-kb-block=\"kb-adv-heading_b4ec59-45\"]{text-align:left;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading_b4ec59-45 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading_b4ec59-45[data-kb-block=\"kb-adv-heading_b4ec59-45\"] mark.kt-highlight{font-style:normal;background:var(--global-palette2, #2B6CB0);-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading_b4ec59-45 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading_b4ec59-45[data-kb-block=\"kb-adv-heading_b4ec59-45\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading_b4ec59-45 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading_b4ec59-45\"><a href=\"https:\/\/maxicaretherapy.com\/dev\/wp-content\/uploads\/2022\/11\/Referral-Sheet.pdf\">Download Referral Sheet<\/a><\/h2>\n\n\n\n<div style=\"height:40px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">Steps on submitting the PDF File:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">1. Download the Referral Form PDF File.<br>2. Make sure to open the file using Adobe Acrobat Reader.<br>3. From the menu of the Acrobat Reader, click on&nbsp;<strong>File<\/strong>&nbsp;and then&nbsp;<strong>Save<\/strong>&nbsp;to save all your entered information.<br>4. Upload the PDF File on our website.<br>5. <strong>If you can&#8217;t do the PDF File submission, you have the option to fill and submit the online form below<\/strong>.<\/p>\n\n\n<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_referral-form3\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Referral Form TOP<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"referral-form3\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"3699fd0024\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/dev\/wp-json\/wp\/v2\/pages\/321\" \/><div id=\"frm_field_107_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_4iivc4\" id=\"field_4iivc4_label\" class=\"frm_primary_label\">Please Select the CITY to CONNECT\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[107]\" id=\"field_4iivc4\"  data-frmval=\"SELECT CITY\" data-reqmsg=\"Please Select the CITY to CONNECT cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please Select the CITY to CONNECT is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"SELECT CITY\" selected='selected'>SELECT CITY<\/option><option  value=\"Maxicare Therapy Chicago, IL\">Maxicare Therapy Chicago, IL<\/option><option  value=\"Maxicare Therapy Las Vegas, NV\">Maxicare Therapy Las Vegas, NV<\/option><option  value=\"Maxicare Therapeutic LLC. Houston, TX\">Maxicare Therapeutic LLC. Houston, TX<\/option><option  value=\"Maxicare Therapeutic LLC. Dallas, TX\">Maxicare Therapeutic LLC. Dallas, TX<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_108_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <label for=\"field_29yf4d4\" id=\"field_29yf4d4_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_29yf4d4\" name=\"item_meta[108]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please enter a valid email address\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_109_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_9jv0r14\" id=\"field_9jv0r14_label\" class=\"frm_primary_label\">Notes\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[109]\" id=\"field_9jv0r14\" rows=\"5\"  data-invmsg=\"Message is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_110_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_s1jh63\" id=\"field_s1jh63_label\" class=\"frm_primary_label\">Select a File to Upload\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"hidden\" name=\"item_meta[110]\"  value=\"\" data-frmfile=\"110\" \/>\n\n<div class=\"frm_dropzone frm_single_upload frm_clearfix\" id=\"file110_dropzone\" role=\"group\" >\n\t<div class=\"fallback\">\n\t\t<input type=\"file\" name=\"file110\" id=\"field_s1jh63\"\n\t\t\t data-invmsg=\"File Upload is invalid\" class=\"auto_width\" aria-invalid=\"false\"  \t\t\t\/>\n\t\t\t\t<div class=\"frm_clearfix \"><\/div>\n\t<\/div>\n\t<div class=\"dz-message needsclick\">\n\t\t<span class=\"frm_icon_font frm_upload_icon\"><\/span>\n\t\t<span class=\"frm_upload_text\"><button type=\"button\">Drop the Referral Form Here<\/button><\/span>\n\t\t<span class=\"frm_compact_text\"><button type=\"button\">Choose File<\/button><\/span>\n\t\t<div class=\"frm_small_text\">\n\t\t\tMaximum upload size: 10MB\t\t<\/div>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_216_container\">\n\t\t\t<label for=\"field_9ykxo\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_9ykxo\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[216]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"Xz8vurMLhLJtN3TBIE9dIkh2dlPY\/HAYz8VcG39we9Y=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n\n\n<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_referral-form\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Referral Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"referral-form\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"3699fd0024\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/dev\/wp-json\/wp\/v2\/pages\/321\" \/><div id=\"frm_field_18_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top\">Referral - Fill & Submit The Referral Form Online<\/h3>\r\n<div id=\"frm_desc_field_3ktmc\" class=\"frm_description frm_section_spacing\">Please Enter \"N\/A\" for fields that are not applicable.<\/div>\r\n\r\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_4iivc2\" id=\"field_4iivc2_label\" class=\"frm_primary_label\">Please Select the CITY to CONNECT\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[10]\" id=\"field_4iivc2\"  data-sectionid=\"18\" data-frmval=\"SELECT CITY\" data-reqmsg=\"Please Select the CITY to CONNECT cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please Select the CITY to CONNECT is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"SELECT CITY\" selected='selected'>SELECT CITY<\/option><option  value=\"Maxicare Therapy Chicago, IL\">Maxicare Therapy Chicago, IL<\/option><option  value=\"Maxicare Therapy Las Vegas, NV\">Maxicare Therapy Las Vegas, NV<\/option><option  value=\"Maxicare Therapeutic LLC. Houston, TX\">Maxicare Therapeutic LLC. Houston, TX<\/option><option  value=\"Maxicare Therapeutic LLC. Dallas, TX\">Maxicare Therapeutic LLC. Dallas, TX<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_1e549a\" id=\"field_1e549a_label\" class=\"frm_primary_label\">Referral Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_1e549a\" name=\"item_meta[22]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_d9yzr\" id=\"field_d9yzr_label\" class=\"frm_primary_label\">Agency\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_d9yzr\" name=\"item_meta[23]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_lsxuq\" id=\"field_lsxuq_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_lsxuq\" name=\"item_meta[24]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_q168e\" id=\"field_q168e_label\" class=\"frm_primary_label\">Contact Person\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_q168e\" name=\"item_meta[25]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_5q8g0\" id=\"field_5q8g0_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_5q8g0\" name=\"item_meta[26]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_enmtm\" id=\"field_enmtm_label\" class=\"frm_primary_label\">Fax\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_enmtm\" name=\"item_meta[27]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first horizontal_radio\">\r\n    <div  id=\"field_lluol_label\" class=\"frm_primary_label\">Please Select\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_lluol_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-18-0\">\t\t\t<label  for=\"field_lluol-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_lluol-0\" value=\"Physical Therapy\"  data-sectionid=\"18\" data-invmsg=\"Please Select is invalid\"   \/> Physical Therapy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-18-1\">\t\t\t<label  for=\"field_lluol-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_lluol-1\" value=\"Occupational Therapy\"  data-sectionid=\"18\" data-invmsg=\"Please Select is invalid\"   \/> Occupational Therapy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-18-2\">\t\t\t<label  for=\"field_lluol-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_lluol-2\" value=\"Speech Therapy\"  data-sectionid=\"18\" data-invmsg=\"Please Select is invalid\"   \/> Speech Therapy<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\r\n    <label for=\"field_bvntq\" id=\"field_bvntq_label\" class=\"frm_primary_label\">Patient's  Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bvntq\" name=\"item_meta[29]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"Patient&#039;s  Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_q2j8t\" id=\"field_q2j8t_label\" class=\"frm_primary_label\">Date of  Birth\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_q2j8t\" name=\"item_meta[30]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"Date of  Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_96qc2\" id=\"field_96qc2_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_96qc2\" name=\"item_meta[60]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_ysobz\" id=\"field_ysobz_label\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ysobz\" name=\"item_meta[32]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm3\">\r\n    <label for=\"field_mvvxn\" id=\"field_mvvxn_label\" class=\"frm_primary_label\">City\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[61]\" id=\"field_mvvxn\"  data-sectionid=\"18\" data-reqmsg=\"City cannot be blank.\" aria-required=\"true\" data-invmsg=\"City is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\">Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_top_container frm3\">\r\n    <label for=\"field_8elp9\" id=\"field_8elp9_label\" class=\"frm_primary_label\">Zip Code\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_8elp9\" name=\"item_meta[37]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_97ieq\" id=\"field_97ieq_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_97ieq\" name=\"item_meta[62]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_r1eav\" id=\"field_r1eav_label\" class=\"frm_primary_label\">Other Phone (If Applicable)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_r1eav\" name=\"item_meta[38]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_v3w2z\" id=\"field_v3w2z_label\" class=\"frm_primary_label\">Certification Period (Start of Episode)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_v3w2z\" name=\"item_meta[33]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_aq1vz\" id=\"field_aq1vz_label\" class=\"frm_primary_label\">Certification Period (End of Episode)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_aq1vz\" name=\"item_meta[41]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_xkgv8\" id=\"field_xkgv8_label\" class=\"frm_primary_label\">Physician Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xkgv8\" name=\"item_meta[40]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"Physician Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_jtm1x\" id=\"field_jtm1x_label\" class=\"frm_primary_label\">Physician Phone\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_jtm1x\" name=\"item_meta[63]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\r\n    <label for=\"field_bofzy\" id=\"field_bofzy_label\" class=\"frm_primary_label\">NPI\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bofzy\" name=\"item_meta[43]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"NPI cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_hyjk7\" id=\"field_hyjk7_label\" class=\"frm_primary_label\">Physician Fax\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_hyjk7\" name=\"item_meta[64]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_b5atx\" id=\"field_b5atx_label\" class=\"frm_primary_label\">Insurance Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_b5atx\" name=\"item_meta[35]\" value=\"\"  data-sectionid=\"18\" data-reqmsg=\"Insurance Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_if6dv\" id=\"field_if6dv_label\" class=\"frm_primary_label\">Other Treatment\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_if6dv\" name=\"item_meta[44]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n    <label for=\"field_lo572\" id=\"field_lo572_label\" class=\"frm_primary_label\">MD Order\/Suggested Frequency\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[49]\" id=\"field_lo572\" rows=\"5\"  data-sectionid=\"18\" data-invmsg=\"Message is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n    <label for=\"field_g70tk\" id=\"field_g70tk_label\" class=\"frm_primary_label\">Diagnosis\/Special Instructions\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[50]\" id=\"field_g70tk\" rows=\"5\"  data-sectionid=\"18\" data-invmsg=\"Message is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_x1ks1\" id=\"field_x1ks1_label\" class=\"frm_primary_label\">ICD-10\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_x1ks1\" name=\"item_meta[51]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Emergency Contact:<\/h3>\r\n\r\n\r\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_j9r7s\" id=\"field_j9r7s_label\" class=\"frm_primary_label\">Name of First Contact\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_j9r7s\" name=\"item_meta[56]\" value=\"\"  data-sectionid=\"52\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_ix5ev\" id=\"field_ix5ev_label\" class=\"frm_primary_label\">Relationship of First Contact\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ix5ev\" name=\"item_meta[55]\" value=\"\"  data-sectionid=\"52\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_j4ag3\" id=\"field_j4ag3_label\" class=\"frm_primary_label\">Phone of First Contact\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_j4ag3\" name=\"item_meta[65]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_baqdb\" id=\"field_baqdb_label\" class=\"frm_primary_label\">Name of Second Contact\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_baqdb\" name=\"item_meta[59]\" value=\"\"  data-sectionid=\"52\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_ix4mi\" id=\"field_ix4mi_label\" class=\"frm_primary_label\">Relationship of Second Contact\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ix4mi\" name=\"item_meta[58]\" value=\"\"  data-sectionid=\"52\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_fc1xt\" id=\"field_fc1xt_label\" class=\"frm_primary_label\">Phone of Second Contact\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_fc1xt\" name=\"item_meta[66]\" value=\"\"  data-sectionid=\"18\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_217_container\">\n\t\t\t<label for=\"field_r8b53\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_r8b53\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[217]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"Xz8vurMLhLJtN3TBIE9dIktRJ6xye0fRxFe5tFMubCs=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n<\/div><\/div>\n<\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Send Referral Form Referral &#8211; Download PDF File &amp; Upload Completed PDF File Download Referral Sheet Steps on submitting the PDF File: 1. Download the Referral Form PDF File.2. 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