PHYSICIAN’S PRESCRIPTION / REFERRAL / MEDICAL NECESSITY      


DATE:  _______________________________


FROM :  DOCTOR  ____________________________________________________

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PHONE:  (       )                                               FAX:  (       )


TO:  LISA SLININGER, LMT(JA #5106), CMT, (CA #2341)   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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