Shockwave Treatment Request Form - Joint Pain Relief - Precision Medical Group

Work Comp - MTUS/ACOEM - FDA Diagnoses

Complete required patient information below.

Patient Name(Required)

First Last

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Sex(Required)

Patient DOB(Required)

Patient SSN(Required)

Patient Cell Phone(Required)

Patient Work Phone(Required)

Treating Physician(Required)

Practice Name(Required)

Physician Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physician Phone(Required)

Location of Clinic where patient is to be treated:(Required)

Diagnosis:

Please Circle: R = right, L = left, B = bilateral *Bilateral each area treated on different dates.

Right Side - M75.31 Calcifying Tendinitis of the Shoulder

Yes

M76.50 - Patellar Tendinitis

Left Side - M75.32 Calcifying Tendinitis of the Shoulder

Yes

M76.60 - Achilles Tendinitis

M75.100 - Non-Calcifying Tendinitis of Shoulder

M76.60 - Achilles Bursitis

M75.40 - Shoulder Impingement

M77.30 - Calcaneal Spur

M77.10 - Lateral Epicondylitis

M72.2 - Plantar Fasciitis

M77.00 - Medial Epicondylitis

Right Side - M70.60 – Trochanteric Tendinitis

TREATMENT INFORMATION:

The patient information listed above was completed by my office staff, or myself, and it is to the best of my knowledge true and factual.

Treatment Area:(Required)

SHOULDER

ELBOW

HIP

KNEE

ANKLE

HEEL

FOOT

OTHER

If you chose Other, please detail here:

Has this patient previously received ESWT treatment?(Required)

On this area?(Required)

Date of previous treatment(Required)

Date of Injury(Required)

Claim Number(Required)

Referring Physician(Required)

Employer's Name(Required)

Employer's Phone Number(Required)

Adjusters Name(Required)

Adjuster's Phone(Required)

Adjuster's Fax(Required)

Carriers Name(Required)

First Last

Carrier's Phone(Required)

Carriers Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

AUTHORIZATION CRITERIA

ESWT is medically necessary for treatment of patients, and as an alternative to surgery, when the following criteria have been met:

Symptoms have persisted for several months.
History of at least three unsuccessful conservative treatments. (Listed Below)

THE PATIENT HAS FAILED TO RESPOND TO THE FOLLOWING CONSERVATIVE TREATMENTS:(Required)

The patient has met the criteria for ESWT treatment and in my medical judgment will benefit with the Sonocur ESWT device.

Additionally,(Required)

The patient information listed above was completed by my office staff, or myself, and it is to the best of my knowledge true and factual.

Physician Name (if different from Treating Physician)(Required)

First Last

SEND RX, DEMOS, PR-2, AND THIS FORM TO:

Submit everything here, or...
FAX: (949) 743-0567
EMAIL: REFERRALS@POMG.NET
PHONE: 888-98-PAINFREE

Attach the RX, Demos, PR-2 here and submit:

Accepted file types: pdf, pdf, Max. file size: 10 MB.