Transcription of Practitioner/Clinic Name: Physician/Health-Care …
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Associated Bodywork & Massage ProfessionalsMEMBERP ractitioner/Clinic Name: Physician/Health-Care Contact Information Provider s Referral Patient Information Patient Name: Date of Birth: Insurance ID#: Date of Injury/Illness: Referred to Provider Name: Specialty/Type of Treatment: Reason for Referral Diagnosis codes ICD-9/10: Number of visits (frequency/duration): Is the referral for medically necessary treatment? Yes No Description of condition: Possible precautions due to condition: Possible interactions with medications: _ Referred by physician /Health-C are Provider Name: Phone: Fax: Email: Signature: Date: Please note: Should you notice anything unusual or significant during treatment, please notify this office immediately.
Associated Bodywork & Massage Professionals MEMBER Practitioner/Clinic Name: Physician/Health-Care Contact Information Provider’s Referral Patient Information
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REGENTS DESIGNATED PHYSICIAN SHORTAGE, REGENTS DESIGNATED PHYSICIAN SHORTAGE AREAS In, REQUEST FOR STATEMENT OF PHYSICIAN, General Medicare Guidelines on Billing for, Physician, 2017 PHYSICIAN PROCEDURES, REFERRING PHYSICIAN Letter of support, Annotated Legal Cases on Physician-Assisted, PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT OF