REFERRAL FOR OUTPATIENT BRAIN
INJURY DAY TREATMENT
FAX to the BRAIN INJURY DAY TREATMENT PROGRAM OFFICE (212) 263-6807 Date: ___________ Patient Name: ____________________ Patient Date of Birth: ______________ Patient Social Security Number: _________ Patient Telephone Number: Contact 1: (_____)_____-_________ Contact 2: (_____)_____-_________ Patient Address: ________________________________________ ________________________________________ Family/Significant Other Contact: Name: ________________ Relationship: ____________ Telephone Number: (_____)_____-_________ Primary Insurance: __________ Policy Number: __________ Insured Name: _______ Secondary Insurance: ________ Policy Number: __________ Insured Name: _______ Prescription for (Please complete only ONE referral section Initial OR Continuation):
Initial Referral
Referral for: _____ Neuropsychological Evaluation _____ Neuropsychological Rehabilitation Do you want us to begin treatment based upon our evaluation findings: Yes / No
(please circle)
Continuation Referral
Referral for: _____ Neuropsychological Rehabilitation Continued Date of Onset of Injury/Illness: _____ Duration: _____ Effective Treatment Dates: (20 Weeks) --
Previous Neuropsychological Evaluation: Yes / No If yes, Date: _____ and please forward (please circle) DSM-IV Diagnosis (if applicable) _____ History of Brain Injury/Illness: Yes / No If yes, Onset Date: _____ (please circle)
ICD-9 Codes: Primary ________ Secondary: ________ Tertiary: ________ (ICD-9 Code Sheet Attached) Medical Diagnosis: _________________________ Medications: _________________________________________________________________ Physician’s Name/Specialty: ____________________________________________________ License Number: ____________ UPIN: __________ NPI# _____________________ Office Telephone: _________________ Office Fax: ______________ Physician’s Signature: _________________________________________
NYU Hospitals Center, Brain Injury Day Treatment Program, 660 1 st Avenue, 3rd Floor, NY, NY10016, (212) 263-7156 www.ruskinstitute.org
BRAIN INJURY DAY TREATMENT PROGRAM ICD-9 CODES
When entering ICD-9 codes, provide each code category with the additional fourth or fifth sub-classification digit, as indicated.
Cerebral Hypoxia (use additional Ecode to identify cause) [348.1] Cerebrovascular Disease Subarachnoid hemorrhage Intracerebral hemorrhage Subdural hemorrhage Late effects: Cognitive deficits Aphasia Dysphasia Other speech and language deficits Hemiplegia and Hemiparesis [430-438] [430] [431] [432.1] [438.0] [438.10] [438.12] [438.19] Meningitis (enterovirus) Bacterial Staphilococcal Intracranial/intraspinal abscess Late effects, intracranial abscess Multiple Sclerosis Other demyelinating [047] [320] [321.1] [324] [326] [340] [341] Multiple fractures skull/ face with other bones Head Injury, Intracranial* Concussion Cerebral laceration/contusion Subarachnoid, subdural, extradural following injury [852] Intracranial, unspecified Hydrocephalus Acquired Communicating
[804] [850-854] [850] [851] hemorrhage [854]
[331.4] [331.3]
[438.2]
Dementia (organic psychotic conditions classified elsewhere) [294.1] Encephalitis (Enterovirus) Viral encephalitis Late effects, viral encephalitis Head Injury, Fracture of Skull* Fracture, vault of skull Fracture, base of skull Other/unqualified fractures [323] [049] [139.0] [800-804] [800] [801] [803]
Nonpsychotic Mental Disorders to Organic Brain Damage [310]
Frontal lobe syndrome Organic personality syndrome Post concussion syndrome Other specified elsewhere Unspecified cause [310.0] [310.1] [310.2] [310.8] [310.9]
Due
*Fourth digit subclassification required for categories [800-804; 850-854]; Use fifth digit to specify LOC; Use E code(s) to identify cause and intent of injury/poisoning [E800-E944]