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To: Utilization review department
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From
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Fax #
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Phone: 832-767-2280
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# of pages
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Fax: 832-767-2314
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Diagnosis
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Requested Services
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Frequency
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Setting
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Claimant Name (First and Last)
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Claimant SSN #
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Claim Number
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Date of Injury
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Requesting Provider: Dr. Mary Ann Spiers, D.C
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Tax ID : 208177595 - NPI: 1285791533
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Address: 4615 Southwest Freeway, Ste 850, Houston, TX - 77027
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Phone - 832-767-2280 - Fax: 832-767-2314
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CODES
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97012
|
97035
|
|
97110
|
G0283
|
|
97124
|
97140
|
|
97545 - WC
|
97546 - WC
|
|
97545 - WH
|
97546 - WH
|
|
SEE ATTACHED MEDICAL RECORDS
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|
