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Get Fl Therapy Network Patient Intake Form 2022-2024

( 88 8) 550- 880 0 x 1 Facility / Group Name TIN Number Facility / Group Address (where services will be rendered) Facility / Group NPI City State Contact Person Fax this request to: Phone Zip Fax Treating Therapist Name (rendering) Treating Therapist NPI Referring Provider Name Referring Provider NPI Patient Last Name Patient First Name Patient ID Patient County Patient Date of Birth (mm/dd/yyyy) Line of Business Medicare Medicaid Medicaid Healthy Kids Plac.

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