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[ Home ] [ Table of Contents ] [ Intro ] [ Cost Per Client ] [ Setting Your Fees ] [ Types of Insurance ] [ Personal Injury ] [ HMO's, PPO's ] [ How to become a p ] [ Contracts ] [ Injured Workers ] [ HCFA Intro ] [ Fill out HCFA ] [ CPT Codes ] [ The ICD-9's ] [ Documentation ] [ SOAP Charting for Massage Therap ] [ Reports ] [ Getting Paid ] [ Networking ] [ In Summary ] [ Issues and Ethics ] [ Glossary A-E ] [ GlossaryF-O ] [ Glossary P-Z ] [ Insurance Benefits Verification ] [ Track communications with the in ] [ Physicians Referral for Massage ] [ Progress Report From ] [ Resources ]
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Physicians Referral for Massage Therapy Services

 

From:______________________________

Patient Name:________________________

Address:____________________________

SS#________________________________

Date of Birth:_________________________

Insurance Company:___________________

Policy Number:______________________

Claim Number:_______________________

Billing Address:______________________

Date of Injury:_______________________

Diagnosis/ICD-9 code(s):______________

__________________________________

__________________________________
__________________________________

___________________________________

Condition is related to ___MVA___work injury

___Other injury ___Stress ___other medical condition

Number of sessions to be done: (frequency and duration)_________________________

____________________________________

Send progress report:

____ every week

____every two weeks

____at the completion of prescribed treatments

____other_____________________

Special directions/Comments:___________

____________________________________

Areas to be worked on: (circle all that apply, add comments)

  

Cranial: Temporalis, Masseter, Frontalis_________________________________________________________

________________________________________________________________

Cervical: E.S, Levator, Scalenes, SCM, Spenius Cervicus/Capitis, Trapezius, Sub-occipitals________________

_________________________________________________________________________________________

Thoracic: E.S, Rhomboid, Serratus Anterior, Trapezius, Serratus posterior superior_______________________

_________________________________________________________________________________________

Shoulder: Infraspinatus, Supraspinatus, Subscapularis, Teres , Deltoid, PecMj, PecMn____________________

_________________________________________________________________________________________

Lumbar: E.S, Quadratus, Iliacus, Psoas__________________________________________________________

Sacral: Gluteus Max, Min, Med, Rotators, IT Band, Quads, Hamstrings, TFL_____________________________

_________________________________________________________________________________________

Other:____________________________________________________________________________________

Hydrotherapy: None, Heat, Cold Location:________________________________________________________

 

 

 

Physicians Signature_______________________________________Date:____________________________

Physicians Name printed:___________________________________________________________________

Address_________________________________________________________________________________

Phone___________________________________________________________________________________

 

Please also check the insurance billing manual updates and the blog for more information.

 

[ Home ] [ Table of Contents ] [ Intro ] [ Cost Per Client ] [ Setting Your Fees ] [ Types of Insurance ] [ Personal Injury ] [ HMO's, PPO's ] [ How to become a p ] [ Contracts ] [ Injured Workers ] [ HCFA Intro ] [ Fill out HCFA ] [ CPT Codes ] [ The ICD-9's ] [ Documentation ] [ SOAP Charting for Massage Therap ] [ Reports ] [ Getting Paid ] [ Networking ] [ In Summary ] [ Issues and Ethics ] [ Glossary A-E ] [ GlossaryF-O ] [ Glossary P-Z ] [ Insurance Benefits Verification ] [ Track communications with the in ] [ Physicians Referral for Massage ] [ Progress Report From ] [ Resources ]




 



 

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