Submit the completed Outpatient Therapy Services Orders Form via fax at 713.797.5988 or email it to Tirradmissionsintake@memorialhermann.org. Ensure to keep a copy for your records after submission. It is advised to follow up with a phone call to 1.800.44.REHAB (73422) to confirm receipt.

Please refer to the 2024 and 2025 schedules for the upcoming therapy programs. Specific dates will be provided during your initial consultation. Staying informed about these dates ensures timely access to necessary services.

The purpose of this form is to facilitate the referral process for outpatient therapy services at TIRR Memorial Hermann. It serves as a key document for gathering essential patient information, diagnosis, and required therapy services. By completing this form, healthcare providers ensure that patients receive appropriate treatments tailored to their needs.

• 1. Patient Name: Enter the patient's full name.
• 2. DOB: Provide the date of birth of the patient.
• 3. Diagnosis: Outline the patient's medical diagnosis.
• 4. ICD 10 Code(s): Enter the relevant ICD 10 codes for the diagnosis.
• 5. Preferred Start Date: Specify the desired start date for therapy services.

Failure to submit this form may result in delays in the patient's therapy process. Without the necessary information, referrals may not be processed efficiently, affecting care timelines.

• Delayed Treatment: Patients may experience postponement of their therapy sessions.
• Incomplete Referrals: Referral services may lack crucial patient details to proceed.
• Miscommunication: Unclear instructions could lead to confusion over therapy requirements.

• 1. Referring Patients: Healthcare providers should use this form to refer patients for services.
• 2. Patient Coordination: Family members coordinating care should fill out this form.
• 3. Insurance Claims: Use this form for claims processing with insurance providers.