{"id":14,"date":"2015-01-09T07:28:44","date_gmt":"2015-01-09T07:28:44","guid":{"rendered":"http:\/\/ncfrp.jeanettekwok.com\/?page_id=14"},"modified":"2015-07-02T11:16:39","modified_gmt":"2015-07-02T11:16:39","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/www.ncfrp.com\/es\/referral-form\/","title":{"rendered":"Referencias"},"content":{"rendered":"<p><\/p>\n<div class=\"check-out-small\"><a href=\"\/referrals\/\" target=\"_blank\">Funcionamiento<\/a> <a href=\"\/wp-content\/uploads\/2015\/01\/NCFRP-REFERRAL-FORM.pdf\" target=\"_blank\">Descargue la forma PDF<\/a><\/div>\n<p><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f204-o2\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/14#wpcf7-f204-o2\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"204\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f204-o2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"referral_form\">\n<h4>INFORMACION DEL PACIENTE<\/h4>\n<p><span class=\"wpcf7-form-control-wrap your-name\"><input type=\"text\" name=\"your-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span><span class=\"wpcf7-form-control-wrap your-date-of-birth\"><input type=\"text\" name=\"your-date-of-birth\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha de nacimiento\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap your-address\"><input type=\"text\" name=\"your-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Domicilio\" \/><\/span>\n<div class=\"three-section\"><span class=\"wpcf7-form-control-wrap your-city\"><input type=\"text\" name=\"your-city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Ciudad\" \/><\/span><span class=\"wpcf7-form-control-wrap your-state\"><input type=\"text\" name=\"your-state\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span><span class=\"wpcf7-form-control-wrap your-zip\"><input type=\"text\" name=\"your-zip\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"C\u00f3digo postal\" \/><\/span><\/div>\n<p><span class=\"wpcf7-form-control-wrap your-phone\"><input type=\"tel\" name=\"your-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"N\u00famero telef\u00f3nico\" \/><\/span>\n<div class=\"two-section\"><span class=\"wpcf7-form-control-wrap your-altphone\"><input type=\"tel\" name=\"your-altphone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"N\u00famero alternativo\" \/><\/span><span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"E-MAIL\" \/><\/span><\/div>\n<div class=\"clear\"><\/div>\n<h4>INFORMACION DE ASEGURADORA<\/h4>\n<p><span class=\"wpcf7-form-control-wrap your-insurance-company\"><input type=\"text\" name=\"your-insurance-company\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Compa\u00f1\u00eda de Seguros\" \/><\/span><span class=\"wpcf7-form-control-wrap company-employer\"><input type=\"text\" name=\"company-employer\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Empleador\" \/><\/span><span class=\"wpcf7-form-control-wrap your-insurance-address\"><input type=\"text\" name=\"your-insurance-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n\" \/><\/span>\n<div class=\"three-section\"><span class=\"wpcf7-form-control-wrap your-insurance-city\"><input type=\"text\" name=\"your-insurance-city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ciudad\" \/><\/span><span class=\"wpcf7-form-control-wrap your-insurance-state\"><input type=\"text\" name=\"your-insurance-state\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span><span class=\"wpcf7-form-control-wrap your-insurance-zip\"><input type=\"text\" name=\"your-insurance-zip\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"c\u00f3digo postal\" \/><\/span><\/div>\n<p><span class=\"wpcf7-form-control-wrap nurse-case-manager\"><input type=\"text\" name=\"nurse-case-manager\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Enfermero administrador del caso\" \/><\/span>\n<div class=\"two-section\"><span class=\"wpcf7-form-control-wrap case-manager-phone\"><input type=\"tel\" name=\"case-manager-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span><span class=\"wpcf7-form-control-wrap case-manager-fax\"><input type=\"tel\" name=\"case-manager-fax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"FAX\" \/><\/span><\/div>\n<p><span class=\"wpcf7-form-control-wrap your-claim-examiner\"><input type=\"text\" name=\"your-claim-examiner\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ajustador\" \/><\/span>\n<div class=\"two-section\"><span class=\"wpcf7-form-control-wrap claim-examiner-phone\"><input type=\"tel\" name=\"claim-examiner-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span><span class=\"wpcf7-form-control-wrap claim-examiner-fax\"><input type=\"text\" name=\"claim-examiner-fax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"FAX\" \/><\/span><\/div>\n<p><span class=\"wpcf7-form-control-wrap your-insurance-email\"><input type=\"email\" name=\"your-insurance-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"E-MAIL\" \/><\/span>\n<div class=\"two-section\"><span class=\"wpcf7-form-control-wrap your-claim-number\"><input type=\"text\" name=\"your-claim-number\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Numero de caso\" \/><\/span><span class=\"wpcf7-form-control-wrap your-date-injury\"><input type=\"text\" name=\"your-date-injury\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha de lesi\u00f3n\" \/><\/span><\/div>\n<div class=\"clear\"><\/div>\n<h4>INFORMACION DE DOCTOR DE TRATAMIENTO<\/h4>\n<p><span class=\"wpcf7-form-control-wrap treating-physician\"><input type=\"text\" name=\"treating-physician\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del Docto\" \/><\/span>\n<div class=\"three-section\"><span class=\"wpcf7-form-control-wrap treat-phone\"><input type=\"tel\" name=\"treat-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span><span class=\"wpcf7-form-control-wrap treat-fax\"><input type=\"tel\" name=\"treat-fax\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"FAX\" \/><\/span><span class=\"wpcf7-form-control-wrap treat-email\"><input type=\"email\" name=\"treat-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"E-MAIL\" \/><\/span><\/div>\n<div class=\"clear\"><\/div>\n<h4>SERVICIOS SOLICITADOS <\/h4>\n<div class=\"PHYSICIAN_SERVICES\">\n<p><span class=\"wpcf7-form-control-wrap checkbox-780\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-780[]\" value=\"Consulta de Restauraci\u00f3n Funcional\/ Evaluaci\u00f3n Inicial\" \/><span class=\"wpcf7-list-item-label\">Consulta de Restauraci\u00f3n Funcional\/ Evaluaci\u00f3n Inicial<\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap checkbox-759\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-759[]\" value=\"Programa de Restauraci\u00f3n Funcional\" \/><span class=\"wpcf7-list-item-label\">Programa de Restauraci\u00f3n Funcional<\/span><\/span><\/span><\/span>\n<\/p><\/div>\n<div class=\"FUNCTIONAL_RESTORATION\">\n<strong>FAVOR DE INCLUIR LOS SIGUIENTES DOCUMENTOS<\/strong><\/p>\n<p>Autorizaciones:<br\/><span class=\"wpcf7-form-control-wrap Authorizations\"><input type=\"file\" name=\"Authorizations\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".doc,.docx,.pdf,.jpg,.gif,.zip,.rar\" aria-invalid=\"false\" \/><\/span><br\/><br \/>\nInformaci\u00f3n general del paciente:<br\/><span class=\"wpcf7-form-control-wrap PatientFaceSheetDemographics\"><input type=\"file\" name=\"PatientFaceSheetDemographics\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".doc,.docx,.pdf,.jpg,.gif,.zip,.rar\" aria-invalid=\"false\" \/><\/span><br\/><br \/>\nReporte de la visita inicial con el Doctor de tratamiento:<br\/><span class=\"wpcf7-form-control-wrap InitialConsultVisitreportwithPTP\"><input type=\"file\" name=\"InitialConsultVisitreportwithPTP\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".doc,.docx,.pdf,.jpg,.gif,.zip,.rar\" aria-invalid=\"false\" \/><\/span><br\/><br \/>\nde las dos \u00faltimas citas de seguimiento:<br\/><span class=\"wpcf7-form-control-wrap Twomostrecentfollowupvisits\"><input type=\"file\" name=\"Twomostrecentfollowupvisits\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".doc,.docx,.pdf,.jpg,.gif,.zip,.rar\" aria-invalid=\"false\" \/><\/span><br\/><br \/>\nCualquier reporte pertinente de  QME, AME, Informes de diagn\u00f3sticos:<br\/><span class=\"wpcf7-form-control-wrap pertinentQMEAMEDiagnosticReports\"><input type=\"file\" name=\"pertinentQMEAMEDiagnosticReports\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".doc,.docx,.pdf,.jpg,.gif,.zip,.rar\" aria-invalid=\"false\" \/><\/span>\n<\/div>\n<div class=\"clear\"><\/div>\n<h4>INFORMACION DE REFERENCIA<\/h4>\n<p><span class=\"wpcf7-form-control-wrap your-ref-name\"><input type=\"text\" name=\"your-ref-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span><span class=\"wpcf7-form-control-wrap your-ref-date\"><input type=\"text\" name=\"your-ref-date\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Fecha\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap your-ref-address\"><input type=\"text\" name=\"your-ref-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n\" \/><\/span>\n<div class=\"three-section\"><span class=\"wpcf7-form-control-wrap your-ref-city\"><input type=\"text\" name=\"your-ref-city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ciudad\" \/><\/span><span class=\"wpcf7-form-control-wrap your-ref-state\"><input type=\"text\" name=\"your-ref-state\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span><span class=\"wpcf7-form-control-wrap your-ref-zip\"><input type=\"text\" name=\"your-ref-zip\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"C\u00f3digo posta\" \/><\/span><\/div>\n<p><span class=\"wpcf7-form-control-wrap your-ref-phone\"><input type=\"tel\" name=\"your-ref-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n<div class=\"two-section\"><span class=\"wpcf7-form-control-wrap your-ref-FAX\"><input type=\"text\" name=\"your-ref-FAX\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"FAX\" \/><\/span><span class=\"wpcf7-form-control-wrap your-ref-email\"><input type=\"email\" name=\"your-ref-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"E-MAIL\" \/><\/span><\/div>\n<div class=\"clear\"><\/div>\n<h4>\u00bfCOMO SE ENTERO DE NOSOTROS?<\/h4>\n<p><span class=\"wpcf7-form-control-wrap your-ref-aboytus\"><input type=\"text\" name=\"your-ref-aboytus\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u00bfCOMO SE ENTERO DE NOSOTROS?\" \/><\/span><\/p>\n<div class=\"clear\"><\/div>\n<div class=\"clear\"><\/div>\n<p><input type=\"submit\" value=\"SEND\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"clear\"><\/div>\n<\/div>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div><\/p>","protected":false},"excerpt":{"rendered":"<p>Funcionamiento Descargue la forma PDF<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v15.7 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.ncfrp.com\/referral-form\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"[:en]Referrals[:es]Referencias[:] - NCFRP\" \/>\n<meta property=\"og:description\" content=\"Funcionamiento Descargue la forma PDF\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.ncfrp.com\/referral-form\/\" \/>\n<meta property=\"og:site_name\" content=\"NCFRP\" \/>\n<meta property=\"article:modified_time\" content=\"2015-07-02T11:16:39+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebSite\",\"@id\":\"https:\/\/www.ncfrp.com\/#website\",\"url\":\"https:\/\/www.ncfrp.com\/\",\"name\":\"NCFRP\",\"description\":\"Northern California Functional Restoration 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