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Physician Referral Form

For Physicians, PAs, ARNPs & Care Coordinators

Fast-track provider referral portal

Submit an order securely, attach the script, and we'll take it from there. Evaluations are initiated within 24–48 hours of receiving a prescription.

24–48 hour start

Evaluations initiated within 24–48 hours of script receipt, on-site at the resident’s community.

Encrypted end to end

Patient information is encrypted in transit and at rest. Attachments are stored encrypted and are never publicly reachable.

Fax still works

Prefer paper? Fax the order to 855.581.1094.

Secure Submission

Submit a referral

Fields marked with an asterisk are required. Everything else helps us prepare, but won't hold up the evaluation.

This form is encrypted in transit and patient information is encrypted at rest. Access is restricted to authorized Align Motion clinical staff and every access is logged.

Referring provider

10 digits

Patient information

Precautions, weight-bearing status, relevant history.

Discipline requested

PDF, JPG, or PNG — up to 25MB each. You may attach more than one.

No file selected

Alternatives

Other ways to order

Fax a paper Rx

855.581.1094

Call our clinical line

203.518.6065

A downloadable PDF referral form will be linked here once the client supplies the final version. [[ PDF REFERRAL FORM ]]