Refer a Patient to Active Life

Referring a patient to Active Life is simple.  Physicians can use their own Rx form, or may download one of Active Life's convenient Rx forms on this page.  Below is a list of documents typically required in order for Active Life to provide products and services, and to bill insurance properly.
  • Referral form signed by a physician that has been signed within the past 6 months.  A valid ICD10 code must be present on the referral form.
  • Patient ID cards, including State issued ID cards and insurance cards.
  • A copy of the physician and/or therapist progress notes that specifically relate to the prescribed service or product, establishing the medical necessity of the prescribed item.
  • Patient demographics.

Universal Rx Pad

Active Life's universal Rx pad can be used for all services types, and for all Active Life patient facilities.
active_life_rx.pdf
File Size: 1335 kb
File Type: pdf
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Compression Rx Pad

Active Life's compression Rx pad is specifically designed to make the referral process easier for physicians and therapists need compression garment therapy for their patients.
active_life_compression_rx.pdf
File Size: 1308 kb
File Type: pdf
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