PHYSICIAN’S PRESCRIPTION / REFERRAL /
LETTER OF MEDICAL NECESSITY

FROM DOCTOR: __________________________________________ DATE:____ / _____ / _____
PHONE: __________________ FAX: ____________________ CELL: ____________________
TO THERAPIST: _____________________ PHONE: (555) 555-5555 FAX: (555) 555-5555
ADDRESS: 1234 West St., Your Town, MN 55555 CELL: (703) 555-5555
REGARDING PATIENT: ___________________________________________________________
TREATMENT IS MEDICALLY NECESSARY.
Please treat the patient for diagnoses indicated below, using the modalities/procedures check-marked below that are within your scope of practice.
MODALITIES / PROCEDURES
97110____ THERAPEUTIC EXERCISE (R.O.M.)
97124____ MASSAGE THERAPY
97140____ MANUAL THERAPY TECHNIQUES
DX CODES
354.0____ CARPAL TUNNEL SYNDROME
723.1____ CERVICALGIA
723.4____ UPPER EXTREMITIES: BRACHIAL NEURITIS / RADICULITIS
724.3____ SCIATICA
724.4____ LUMBOSACRAL / THORACIC NEURITIS OR RADICULITIS (LOWER EXTREMITIES)
729.1____ FIBROMYALGIA / MYALGIA / MYOSITIS
784.0____ HEADACHE
840.9____ SHOULDERS-UPPER ARMS 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
Other Codes: _________________________________________________________________

PHYSICIAN’S SIGNATURE: __________________________________________________
LICENSE#: ____________________ UPIN#: ____________________
# OF VISITS: ______ # OF TIMES PER WEEK: ______ # OF WEEKS: ______
SPECIAL NOTES: __________________________________________________
__________________________________________________________________