PRESCRIPTION / LETTER OF REFERRAL
“THE FOLLOWING PRESCRIBED TREATMENT IS MEDICALLY NECESSARY”
DATE ______/______/______
PATIENT______
PHYSICIAN______ADDRESS ______
PHONE ______FAX: ______
REFERRED TO: ____________Phone: ______
Any of the following Physicians’ Current Procedural Terminology, CPT™ procedures and / or modalities, which are within this therapists’ scope of practice training, & / or State & / or Patient’s Insurance Policy regulations, may be used as therapist deems necessary during any treatment session.
Normally four procedure units & 2 max modalities allowed per visit. A Unit = 15 - minutes. Conditions or prescription may require more units.
PROCEDURES and MODALITIES
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Vivian Madison Copyright © 1989 – Revised 2004
97010 HOT/COLD PACKS (as necessary)
97014 ELECTRIC STIMULATION, un-attended
97018 PARAFFIN BATH
97022 WHIRLPOOL
97026 INFRARED
97032 ELECTRICAL STIMULATION, attended
97034 CONTRAST BATHS
97035 ULTRASOUND
97036 HYDROTHERAPY (full immersion)
97039 UNLISTED MODALITY, by report
97124 MASSAGE THERAPY
97139 UNLISTED PROCEDURE, by report
97140 MANUAL THERAPY TECHNIQUES
97799 Unlisted Physical Medicine Rehab …… Service or Procedure(By Report) (Initial or Re Assessment
_____ OTHER ______
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Copyright 1990 All Rights Reserved: Comprehensive Guide To Insurance Billing For Massage Therapy Professionals
“CPT © 1998 American Medical Association, All Rights Reserved”
Latest Revision 8/25/99 Author, Vivian Madison - Mahoney
PHYSICIAN’S ICD- 10 DIAGNOSIS OF PATIENT
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Copyright 1990 All Rights Reserved: Comprehensive Guide To Insurance Billing For Massage Therapy Professionals
“CPT © 1998 American Medical Association, All Rights Reserved”
Latest Revision 8/25/99 Author, Vivian Madison - Mahoney
______MIGRAINES
______HEADACHES
______CERVICAL, Inc. Whiplash Injury Sprain / Strain
______JAW (TMJ & Ligament) Sprain /StrainR ___ L____
______CERVICALGIA (pain in neck)
______INFRASPINATUS Sprain / Strain R_____L _____
______SUBSCAPULARIS Sprain /Strain (muscle)R_ __ L ______
______SUPRASPINATUS Sprain/ Strain (muscle)R_ __ L ______
______SHOULDER & ARM (unspecified site)R ___ L______
______ELBOW & FOREARM (unspecified site)R ___ L _____
______WRIST Sprain / Strain (unspecified site)R ___ L _____
______CARPAL TUNNEL SYNDROMER ___ L _____
______HAND Sprain / Strain (unspecified site)R ____ L _____
______PAIN IN THORACIC SPINE
______THORACIC (DORSAL) Sprain / Strain
______LUMBAR Sprain / Strain
______PELVIS (unspecified site) Sprain / Strain
______HIP & THIGH (unspecified site)
______SACROILIAC REGION (unspecified site) Spr/Str
______SACRUM Sprain / Strain
______LUMBOSACRAL RADICULITISR _ L_
______SCIATICA (neuralgia, neuritis) R _ L _
______KNEE OR LEG Sprain/StrainR _ L _
______ANKLE (unspecified site) Sprain/StrainR _ L _
______FOOT (unspecified site) Sprain/StrainR _ L _
______MYOFIBROSIS; muscles, ligament, fascia
______SPASM OF MUSCLE______
______MYALGIA & MYOSITIS (Fibromyositis)
______Unspecified Disorder of Muscle, Ligament, Fascia
______
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Latest Revision 2/15/2018 Author,Vivian Madison - Mahoney
Times Per Week: ______for _____ Weeks, OR Times Per Month: ______for ______Months, or Total Visits This Script ______
Patient to return or call, prior to renewal of prescription
PLAN OF CARE / COMMENTS:
______
PHYSICIAN'S SIGNATURE: ______NPI #: ______
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Latest Revision 2/15/2018 Author,Vivian Madison - Mahoney