PHYSICIAN’S PRESCRIPTION / REFERRAL / MEDICAL NECESSITY
DATE: _______________________________
FROM : DOCTOR ____________________________________________________
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PHONE: ( ) FAX: ( )
TO: LISA SLININGER, LMT, CMT, CMMT PH: (916) 817-2424 , FAX: (916) 608-2196
INTENSE THERAPY LLC, 312 Natoma St., Suite. 130, Folsom, CA 95630
REGARDING PATIENT: ________________________________________________
TREATMENT IS MEDICALLY NECESSARY. Please treat the patient for the diagnoses indicated below, using the modalities/procedures check marked below which are within your scope of practice.
MODALITIES / PROCEDURES (15 MINUTE INCREMENTS)
97010____ HOT OR COLD PACKS/MOIST HEAT
97110____ THERAPEUTIC EXERCISE (R.O.M.)
97112____ NEUROMUSCULAR RE-EDUCATION
97124____ MASSAGE THERAPY (including petrissage and effleurage)
97140____ MANUAL THERAPY TECHNIQUES (including MYOFASCIAL/SOFT TISSUE)
DX CODES
354.0_____ CARPAL TUNNEL SYNDROME
719.41____ SHOULDER PAIN
719.42____ ELBOW PAIN
719.43____ WRIST PAIN
719.45____ HIP PAIN
719.46____ KNEE PAIN
723.1 ____ CERVICALGIA, NECK PAIN
723.4 ____ UPPER EXTREMITIES: BRACHIAL NEURITIS / RADICULITIS
724.1 ____ BACK PAIN, THORACIC
724.2 ____ LOW BACK PAIN/LUMBALGIA
724.3 ____ SCIATICA
724.4____ LUMBOSACRAL / THORACIC NEURITIS OR RADICULITIS (Lower Extremities)
724.8 ____ MUSCLE SPASMS, BACK
729.1____ FIBROMYALGIA / MYALGIA /MYOFASCITIS/MYOSITIS
784.0____ HEADACHE
840.9____ SHOULDERS-UPPER ARMS SPRAIN/STRAIN
842.0____ WRIST SPRAIN/STRAIN
843.8____ HAMSTRING SPRAIN/STRAIN
846.0____ LUMBOSACRAL SPRAIN / STRAIN
847.0____ CERVICAL SPRAIN / STRAIN
847.1____ THORACIC SPRAIN / STRAIN
847.2____ LUMBAR SPRAIN / STRAIN
847.3____ SACRAL SPRAIN / STRAIN
847.4____ COCCYX SPRAIN / STRAIN
848.1____ T.M.J. SPRAIN / STRAIN
PHYSICIAN’S SIGNATURE_____________________________________________________________
LICENSE#________________________________________UPIN#______________________________
# OF VISITS______ # OF TIMES PER WEEK_______ # OF WEEKS ______
SPECIAL NOTES______________________________________________________________________
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