Physical/Occupational Therapy Referral

Functional Capacity Evaluation (FCE)
NES is proud to offer online referrals of the following services. This enables those organizations that our paperless or have scanned in medical records to upload their files directly to the treating therapist and minimize time spent organizing information for faxing and/or mailing. All information uploaded over the NES website is done so over a secured server that is HIPAA compliant. Upon receipt of your referral information NES will follow up with the referral source and schedule the subsequent evaluation within 24 hours.

Sample Functional Capacity Evaluation
HIPAA Compliance Information

Part 1 of 8
Referral Information
Referer:
Organization:
Name:
Address1:
Address2:
City:
State:
Zip Code:
Phone #:
Fax:
Email:
Part 2 of 8
Claimant Information
Name:
Address1:
Address2:
City:
State:
Zip Code:
Phone #:
Fax:
Email:
Part 3 of 8
Case Information
Adjuster:
Adjuster Phone #:
File/Claim No.:
Date of Birth:
Occupation:
Job Description:
Type of Injury:
How Injury Occurred:
Injury Date:
Diagnosis Code:
Diagnosis Description:
Insurer:
Attorney:
Attorney Phone #:
Include Attorney in Correspondence: Yes No
Part 4 of 8
Employer Information
Name of Company:
Email:
Address1:
Address2:
Phone #:
Contact Person:
Are Physical Demands (or Job Demands) Available? Yes No
Is this a job-specific FCE? Yes No
Part 5 of 8
Location:
Please select location:
Part 6 of 8
Type of Case
Liability
LTD (Long Term Disability)
STD (Short Term Disability)
Long Shore
State/Government Agency
Legal
Workers Compensation
Part 7 of 8
Questions to be Answered
What is claimant's current work capacity
Did the claimant provide full physical effort during testing?
Is the claimant capable of performing [his/her] pre-injury job. If not, what are [his/her] physical abilities?
Are the claimant's subjective reports reliable?
What are the claimant's physical work tolerances?
Can the claimant return to work full time? If not, how many hours?
Write in additional questions and/or information:
Part 8 of 8
Medical Records Secure Upload
We accept PDF, DOC and JPG format. File upload limit is 20MB
File #1:
File #2:
File #3:
File #4:
File #5:
File #6:
Important Note
Hard copy information can be sent to the following:

Fax: 603-742-1414

Mailing Address: Northeast Evaluation Specialists, PLLC
1 Washington St. Suite 443
Dover, NH 03820

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