Referral form

Myopathic Muscular Therapy Clinic
Member MMTA, NCBTMB, AMTA4610 200th ST SW Suite NLynnwood, WA 98036
Phone: (425)712-0852   Fax: (425)712-0854
Osmarina Santana, LMP, MyP License# MA6448
Patient Name:

Please provide the following medically necessary treatment(s) for this patient.

Diagnosis:
M54.2 Neck Pain and stiffness 846.0 Lumbosacral Sprain
723.4 Upper Extremities:
BrachialNeuritis / Radiculitis
847.0 Cervical Sprain/Strain
724.3 Sciatica S233XXD Thoracic Sprain/Strain
724.4 Lumbosacral/Thoracic
Neuritis
or Radiculitis (Lower Extremities)
S335XXD Lumbar Sprain/Strain
729.1 Fibromyalgia/Myalgia/Mytosis 847.3 Sacral Sprain/Strain
840.9 Shoulders-Upper Arms

Sprain/Strain

784.0 Headache

 

Other DX:

 

Modalities / Procedures
97140

97124

– Myopathic Muscular Therapy

– Massage Therapy

1 – 3 x p/week as needed
Precautions:  

 

Referring Physician: Phone:
Physician’s Signature: Date:
Fill out form. Print, sign and FAX to: MMTC
(425)712-0854
Lynnwood, WA