Printable
The referral pad
A stack of single 8.5 × 11 sheets a prescriber fills out and faxes back. Offer one to every office you visit, whether or not they ask.
Supports Stage III, Step 1: Prepare Your Activities of Frameworks. Read the book →
The pad is the piece of outreach material that does the most work, because it removes the two things that stop a busy office from referring: not knowing what to write, and not knowing where to send it. Everything on the sheet below is there for one of those two reasons.
Full sheets only. A smaller pad is tempting given how simple a massage referral is, and it is the wrong call. Anything under 8.5 × 11 is awkward to feed through a fax machine, and multi-part carbon sets are both cumbersome and a HIPAA problem. Stick to standard paper.
What has to be on it
- Your clinic name, phone, fax and address. As much for the front-office staff as for the patient who leaves with a copy of the prescription in hand.
- One instruction about what to do with it. “Fax prescriptions to (555) 555-0101” is enough. It looks redundant until the third phone call from an office assistant asking what you want her to do with the sheet.
- Treatment goals that can be checked off. Insurers often require them, and a prescriber composing goals from scratch writes fewer referrals than one ticking boxes. The book names three by example; the rest of the list below is the same idea extended.
- The prescriber’s name, phone and office address — spelled correctly, and printed clearly, because documents lose clarity every time they are faxed. This is for you and for whichever insurer later wonders whose signature is at the bottom.
- A map and directions on the back of every page. Black and white, major streets and landmarks only. Not a Google Maps screenshot — there is far too much in one to survive a static black-and-white reproduction.
The pad itself
Print it, replace everything in square brackets, and read it back as though you were the office assistant holding it. Anything you cannot answer from the sheet alone is something to fix before you have a hundred of them padded.
[Your clinic name]
[Street address] · [City, State ZIP] · Phone [(555) 555-0100] · Fax [(555) 555-0101]
Fax prescriptions to [(555) 555-0101]
Prescription for massage therapy
Patient name
Date of birth
Insurer / claim or policy no.
Date of injury
Diagnosis
Code
Treatment goals — check all that apply
- Decrease Muscle Pain
- Resolve Muscle Spasms
- Increase Range of Motion
- Decrease Myofascial Trigger Point Pain
- Decrease Swelling and Edema
- Improve Soft Tissue Extensibility
- Improve Tolerance for Activities of Daily Living
- Support Return to Work or Sport
- Other (write below)
Other
Frequency and duration
Visits per week
For (weeks)
Minutes per session
Referring provider
Name (please print)
Phone
Office address
NPI
Signature
Date
Directions to our office are on the back of this sheet. A copy may be given to the patient.
[Your clinic name]
[Street address] · [City, State ZIP] · Phone [(555) 555-0100] · Fax [(555) 555-0101]
Finding us
[Place your map here]
Black and white, and simple enough to read at this size after a photocopy. Major streets, one or two landmarks, your building, and a north arrow. Not a Google Maps screenshot.
Driving directions
From the north
From the south
Parking
Nearest transit
To schedule: [(555) 555-0100]
Please bring this prescription and your insurance card to your first visit.
Prints as two letter sheets: the prescription form, then the map side. Print double-sided, then have a print shop pad fifty to a hundred sheets onto a cardboard backing, glued along the top edge. Ctrl/Cmd + P does the same thing as the button.
Adapting it
The goals list is a suggestion, not a standard. Check what your own state and the insurers you bill actually require on a prescription before you pad a hundred sheets — some want a diagnosis code, some want a signed treatment plan instead, and a few want both. Getting that wrong is expensive at pad quantities and invisible until the first denial.
The prescriber block asks for a printed name as well as a signature on purpose. You will be reading these off a fax, and a signature is not a name.
When you deliver the pad, do not just hand it over. Walk the person through one — point at the diagnosis line, point at the goal boxes, and use the condition they have just told you they see most. The pad is the excuse for that conversation, not a substitute for it.
The map back doubles as the thing you nest into patient material for offices that decline a pad. See the rack card.
Written for licensed practitioners. Nothing here is legal or billing advice: what a prescription must contain to be reimbursable is set by your state’s scope of practice and by each insurer, and both drift.