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Massage Therapy of Winter Haven, P.A. Angie R. Horton, L.M.T., C.I.M.I. |
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| Specializing in Corrective Muscle Therapy and Rehabilitation | |
| Lic# MA10610 * MM008310 * RPT17763 | |
| Prescription / Letter of Referral | |
| For: (Patients Name) ______________________________________ Date: _________________________ | |
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____Private Health Care
____PIP Auto ____Workmens' Com. (please check one) |
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| Medically Necessary | |
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Procedures / Modalities: |
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| __ Evaluate and Recommend | 97001 __ Physical Therapy Evaluation |
| 97140 __ Myofascial Release | 97001 __ Physical Therapy Re-evaluation |
| 97124 __ Therapeutic Massage | 97012 __ Traction |
| 95831 __ Muscle Testing (manual) | 97035 __ Ultrasound |
| 97530 __ Therapeutic Activities | 97014 __ Electric Stimulation (attended) |
| 97010 __ Hot/Cold Pacs | 97032 __ Electric Stimulation (unattended) |
| 97110 __ Passive/Therapeutic Exercise | 97112 __ Neuromuscular Reeducation |
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Diagnosis: |
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| 784.0 __ Headaches | 847.2 __ Lumbar Strain/Sprain |
| 729.1 __ Myofascial Pain Syndrome | 846.9 __ Lumbosacral Strain/Sprain |
| 847.0 __ Cervical Strain/Sprain | 724.3 __ Sciatica Pain: Location |
| 840.0 __ Shoulder Strain/Sprain | 848.5 __ Pelvic Strain/Sprain |
| 723.4 __ Upper Extremities: __R __L __ Both | 724.4 __ Sacrum |
| 847.1 __ Thoracic Strain/Sprain | 729.1 __ Fibromyalgia |
| __ Other________________________ | __ Other_________________________ |
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Treatment Plan: |
Authorization: |
| ____ Evaluation and Recommendation, or | Physicians Name:__________________________________ |
| ____ X Per Week for ___ Weeks, or | Signature:________________________________________ |
| ____ Total # of Treatments this RX | Address: _________________________________________ |
| Phone:_____________________ Fax:__________________ | |
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Prescription form must be printed & signed by a physician & the original
faxed or mailed to: |
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