Physical Therapy Rx
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Carrier
Claim #
Attorney Information
SURGERY INFORMATION
Has the patient undergone surgery?
Yes
No
Date of Surgery
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Area
- Select -
Ankle/Foot
Elbow
Hand/Wrist
Hip
Knee
Shoulder
Foot/Ankle
Other
Side
Left
Right
Procedure
THERAPY ORDERS
Need
Physical Therapy
CNA
RN Services
Orders/Comments
Diagnosis
M25.561 Pain in right knee
M25.562 Pain in left knee
M79.601 Pain in right arm
M79.602 Pain in left arm
M79.604 Pain in right leg
M79.605 Pain in left leg
M79.621 Pain in right upper arm
M79.622 Pain in left upper arm
M79.631 Pain in right forearm
M79.632 Pain in left forearm
M79.641 Pain in right hand
M79.642 Pain in left hand
M79.644 Pain in right finger(s)
M79.645 Pain in left finger(s)
M79.651 Pain in right thigh
M79.652 Pain in left thigh
M79.661 Pain in right lower leg
M79.662 Pain in left lower leg
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M54.2 Pain in the cervical spine
M54.6 Pain in the thoracic spine
M54.5 Pain in the lumbar spine
Referring Physician
Dr. Patrick J Mixa
Submit
Should be Empty: