Referral form

 

Myopathic Muscular Therapy Clinic
4610 200th ST SW Suite N – Lynnwood, WA 98036

  Phone: (206) 941-3437   
  Osmarina Santana, LMP, MyP License# MA6448  Member MMTA, NCBTMB, AMTA
  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
       
Other DX:
Modalities / Procedures
97140 – Manual Therapy                                           97124 – Massage therapy              
Precautions:  
Referring Physician:   Phone:  
Physician’s Signature:   Date: