Rehab Referral Service - Request an Appointment

Please complete this form if you would like us to contact you to help schedule an appointment with the appropriate outpatient rehabilitation center. Our Rehabilitation Referral Service will typically respond within one business day.

You can also request an appointment by calling +1.800.493.0039 (Monday-Friday 9am-5pm ET).

Required fields in bold.

Tell us who you are

I am a:


How did you hear about HSS?:

Contact Information

Daytime Telephone:

Email Address:

Patient Information

Date of Birth:

What would the patient be coming to therapy for?:

Does the patient have a prescription from their physician for therapy?:

Where is the patient's physician's office located?: (City, State)

Patient's Insurance Plan:

Other Insurance:

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