For referrers

Refer a patient

Type it or upload it — either takes minutes. Don't hold a referral waiting on records or a job description; send what you have and the rest can follow. Prefer paper? Fill the form and print it — it's formatted for fax.

REHAB AT WORK — Patient Referral

Fax to the clinic nearest the patient (directory on reverse) · (888) 827-6361 · WWW.REHABATWORK.COM

Who's referring

Your name *

Role

Organization

Phone *

Fax (for reports)

The patient

First name *

Last name *

Date of birth

Phone

Street address *

Apt / suite

City *

State *

ZIP *

Preferred language

English Español Other

The case

Claim type

Workers' comp Liability Commercial insurance Self-pay Other

Claim number

Date of injury

Diagnosis / ICD-10 (if known)

Employer & job title (for job-specific programs)

What do you need

Service

Primary goal

Preferred clinic

Records / prescription / job description will follow separately

Anything else we should know

Other parties on the case (optional — helps our reports reach everyone)

Adjuster (name / phone)

Nurse case manager

Attorney (plaintiff or defense)

Referring physician

or use the current secure portal

Prefer another way?

Fax or phone works just as well.

Fax a prescription or your own cover sheet straight to the clinic nearest the patient — or call (888) 827-6361 and we'll take it over the phone. See what happens after you refer →

Clinic	Phone	Fax
Alexandria, VA	(703) 933-1700	(703) 933-8600
Baltimore, MD	(410) 866-3855	(410) 866-3877
Columbia, MD	(443) 546-3884	(443) 546-3669
Frederick, MD	(301) 620-9111	(301) 620-0070
Glen Burnie, MD	(410) 990-1060	(410) 990-1061
Herndon, VA	(703) 705-4665	(703) 740-4952
Lanham, MD	(301) 306-4500	(301) 306-4503
Manassas, VA	(703) 392-7508	(703) 392-6710
Rockville, MD	(301) 251-3757	(301) 251-3731
Waldorf, MD	(301) 893-2366	(301) 893-0609