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PRS PT Appointment Request - DIRECT ACCESS - REVISED

1. What type of appointment are you looking for? *This question is required.
Please complete the following Direct Access Physical Therapy form and our staff will help you find a physical therapist who best fits your individual needs.

Direct Access Physical Therapy is the ability to be evaluated and treated for non-surgical injuries or orthopedic conditions by a physical therapist without a physician prescription.

If you prefer, you may also call us at 800.493.0039. (Monday to Friday, 9:00 AM - 5:00 PM, ET)


 
Please complete the following form and our staff will help you find a physician who best fits your individual needs.

If you prefer, you may also call us at 877.606.1555. (Monday to Friday, 8:30 AM - 5:00 PM, ET)

 
This question requires a valid date format of MM/DD/YYYY.
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Do you have a prescription for physical therapy? *This question is required.
This form is for those without a physician prescription. You may proceed directly by calling any of our rehabilitation locations.
2. Patient Information
This question requires a valid email address.
Gender *This question is required.
mm/dd/yyyy This question requires a valid date format of MM/DD/YYYY.
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If the age calculated is incorrect, please check the date of birth you entered.
3.
Preferences
Preferred Locations *This question is required.
4.
Insurance
In addition to physicians in your network, would you also like to consider physicians who are out of network?
Please note: Based on your selections, direct access to physical therapy is not available at this time. You will need to obtain a prescription for physical therapy from a physician.
Would you like help finding an HSS physician?
Thank you. Please continue filling out our form and our Physician Referral Service will help you find an HSS physician.