For Healthcare Providers
Becoming Our Referring Provider
Partner with us to give your patients a trusted, cause-first path back to movement.
Why Partner With Us
A referral you can trust.
Whether you’re a physician, chiropractor, or other healthcare provider, we’d welcome the chance to partner with you. When you refer a patient to Cupertino Physical Therapy, they get one-on-one care with a Doctor of Physical Therapy: a cause-first evaluation and a plan with a clear endpoint, not a revolving door of aides.
Interested in becoming an approved referring provider, or being listed on our provider network? Reach out and we’ll follow up directly.
Or call our office at (408) 873-8188. See our current provider network.
Referral Pad
Refer with one form.
Print our physical therapy prescription pad, fill it out, and fax or hand it to your patient. It’s everything we need to get them evaluated fast.
Download Provider Referral (opens in a new tab)Prefer to fax it directly? Fax: (408) 873-8138
What’s on this form (text version)
Physical Therapy Prescription — Cupertino Physical Therapy, 1054 S De Anza Blvd, #120, San Jose, CA 95129. Phone (408) 873-8188, fax (408) 873-8138.
Fields to fill in: patient name and date; diagnosis / ICD-10 code; comments or precautions; an “Evaluate & Treat As Appropriate” checkbox.
Services to check (check any that apply): Strength / ROM / Stretching, Pain Relief Modalities, Patient Education, Neck Stabilization Program, Back Stabilization Program, Vestibular Therapy, Balance Training, Gait Training, Functional Training, Manual Therapy, Massage, Knee Rehabilitation, Pelvic Floor Therapy, As Indicated by Therapist, or Other (write-in).
Treatment frequency: visits per week and number of weeks.
A certification statement (“I certify that the prescribed rehabilitation is medically necessary”), with a line for the physician’s signature and date.