|
Rehab/PT:
|
|
|
Rehab/PT Freetext for Recommending PT (for MACRO):
|
|
|
Rehab/PT Switch for Recommending PT:
|
Recommend Rehab/PT:
|
|
Rehab/PT Switch for patient that has already attempted PT.
|
Tried Rehab/PT:
|
|
Recommended Procedure:
• • •
|
Recommended Procedure Comments
|
|
Multiple Select Education
• • •
|
|
|
PROCEDURE:
• • •
|
PROCEDURE Comments:
|
|
MEDICAL NECESSITY PROCEDURE
|
|
|
Gen Block Medical Necessity
|
Gen Block MN
|
|
Cervical MBB Medical Necessity
|
Cervical MBB MN
|
|
RFA Medical Necessity
|
RFA MN
|
|
Epidural Medical Necessity
|
Epidural MN
|
|
Gen RFA Medical Necessity
|
Gen RFA MN
|
|
Lumbar MBB Medical Necessity
|
Lumbar MBB MN
|
|
SI Joint Injection (Diagnostic)
|
SI Joint Injection (Diagnostic)
|
|
Imaging/Diagnostic Tests:
• • •
|
Imaging/Diagnostic Tests Comments:
|
|
MEDICAL NECESSITY DIAGNOSTIC:
|
|
|
EMG/NCS Medical Necessity
|
EMG/NCS Medical Necessity
|
|
MRI Medical Necessity
|
MRI Medical Necessity
|
|
|
Medications Comments:
|
|
AFFIRMATION STATEMENT:
|
AFFIRMATION STATEMENT:
|
|
SIGNATURE:
|
SIGNATURE:
|
