Lower Extremity Functional Index

Patient Summary Form

LEFS (other FOM) 1. Name of the billing provider or facility (as it will appear on the claim form) 2. Federal tax ID(TIN) of entity in box #1 4. Alternate name (if any) of entity in box #1 6. Phone number 1 MD/DO 2 DC Both PT and OT MT Other 3° 4° Health plan Group number Referring physician (if applicable) 1° ATC Anticipated CMT Level

  Form, Patients, Summary, Fels, Patient summary form

HealthFirst NY PT Req Frm-2020 (61463 - Activated ...

LEFS DASH KSS Other: Progress since first visit: None, first visit No Progress Yet Some Progress Significant Progress Significantly Worse Muscle Strength (MMT): 5/5 4/5 4-/5 3+/5 3/5 3-/5 2+/5 2/5 1/5 0/5 Most Recent Score Pain Intensity (0-10): Last 24 hours Past Week Healthfirst Member ID Number 61463 61463

  Fels

電動グリッパ

lefs lefb lel lejs lejb lem ley leyg les lesh lepy leps ler leh ley-x5 11-lefs 11-lejs 25a-

  Fels

電動ロータリテーブル

lefs lefb lel lejs lejb lem ley leyg les lesh lepy leps ler leh ley-x5 11-lefs 11-lejs 25a-

  Fels

Hip - Greater Trochanteric Pain Syndrome

BRIGHAM AND WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy Standard of Care: Greater Trochanteric Pain Syndrome ICD 9 Codes: 726.5, enthesopathy of hip Case Type / Diagnosis: