HTML Preview Chiropractic Treatment Review Template page number 1.
Chiropractic Treatment Plan
Chiropractic Care of Minnesota, Inc.
FAX (800) 599-8350
Date of this Request_____/_____/______
Please check type of care:
Initial care Continuing care Retrospective Review
1
st
Request after Waiver Program
Patient Last Name
Patient First Name
M.I.
Gender
M F
Age
Date of Birth (MM/DD/YYYY)
____/____/_______
Insured I.D. or SSN
Insured Last Name
M.I.
First Name
Patient Phone (area code first)
Patient Address
City
State
Zip Code
Employer Name
Insurance Company
Group Plan # or Union Local (Submit Copy of Patient’s
Insurance I.D. Card)
Injury or illness is related to:
Work Auto Other
Does the patient have other insurance that might cover
this injury/illness? Yes No
Other carrier’s name:
N/A
Doctor Last Name
Doctor First Name
M.I.
Area Code + Phone
( )
Area Code + Fax
( )
Doctor Address
City
State
Zip Code
Doctor License #
Subjective Complaints:
Mechanism of Onset for Primary Diagnosis
Date of Onset (MM/DD/YYYY)
___/___/_____
Acute trauma Worsening of prior illness/injury
Repetitive motion Gradual onset
Chronic Old trauma
Description:
Lost days from work to date ________ Days of work restriction to date _________
Date of first tx at this office for this condition ____/____/_____
Objective Findings Date Obtained ____/_____/______
VITALS: HT: WT: BP: Temp:
Inspection:
Palpation:
Cervical ROM
____°
____°
____°
____°
____°
____°
WNL
Flexion
Extension
R. Lat. Flex
L. Lat. Flex
R. Rotation
L. Rotation
_
__
_
°
_
__
_
°
_
__
_
°
_
__
_
°
__
__°
_
__
_
°
Lumbar ROM
Does the patient indicate that any of these conditions are
present on a patient intake form or during your exam?
(please check all that apply)
Articular derangements (arthritides, autoimmune
diseases, joint instability or hypermobility, etc.)
History of infection (recent fever >100, constant low-
grade fever, bone or joint infection, etc.)
Circulatory or cardiovascular disorders (e.g., stroke)
Bone weakening or destructive disorders (e.g., tumors)
Neurological disorders (myelopathy, acute cauda
equina syndrome, multiple sclerosis, etc.)
Atrophy in the extremities
Abnormal deep tendon reflexes or motor weakness
Scoliosis >20 degrees adult or >10 degrees for child
Congenital connective tissue disorders
Abnormal bowel or bladder function
Signs or symptoms of vertebro basilar insufficiency
Fever or localized redness and swelling or ankylosing
spondylitis
Signs or symptoms of cancer or chemotherapy tx
Signs or symptoms of organic disease
For any checked items, please attach explanation.
Patient is currently under PCP or medical specialist
care; or referred on ___/___/___
Summary of Examination Findings
1
Localized pain reproduced on palpation or orthopedic testing (list area) ___________
2
Radiating pain below knee or elbow reproduced on nerve compression or stretch test
(list nerve root distribution) ______________________________________________
3
Pain referred from muscles or trigger points (list) _____________________________
4
Diffuse ache on passive motion (list joint/s) ________________________________
5
Testing revealed pain, swelling or instability of joint or extremity (list) _____________
___________________________________________________________________
6
Neurological tests within normal limits
7
Neurological deficits (describe):
ICD-9 Code
(list NMS codes only) Description
Pain intensity according to patient
None 0 1 2 3 4 5 6 7 8 9 10 Severe
Symptom frequency according to patient
0-25% 26-50% 51-75% 76-100%
1. Primary __________
_______________________
2. Secondary __________
_______________________
3. Additional __________
_______________________
4. Additional __________
_______________________
X-Rays Requested: Yes No Taken: Yes No
3 view cervical, CPT 72040 (AP, APOM, LAT)
2 view thoracic, CPT 72070 (AP, LAT)
2 view lumbar, CPT 72100 (AP, LAT)
Other ____________ CPT ____________
Medical X-ray Findings
WNL
Positive for:
Fracture/Dislocation
Gross Osseous Pathology
Pathology as noted
below:
Chiropractic X-Ray Findings Date taken ____/____/_____
Describe:
Treatment Plan (MM/DD/YYYY)
From ____/_____/________
To ____/_____/________
No. of Visits Requested_______
Proposed Adjustive Techniques
Manual Technique(s):
Diversified
Gonstead Activator Other____________
Comments/Goal of Tx
Reduce pain _____ %
Improve ROM _____ %
Other:
Anticipated release date ____/_____/________
Complicating Factors
(Check any that apply and/or list)
Poor tissue healing such as: pernicious anemia, diabetes,
thyroid disease
Other:
Anatomical deficit such as: asymmetrical facets, djd, spinal
stenosis, spondylolisthesis, congenital or acquired joint
anomaly, 3
rd
trimester pregnancy, >100 lbs. overweight
Other:
Patient Home Care
Stretching Exercise Hot/cold
I declare that the above information is true and correct to the best of my knowledge.
Signature _____________________________________Date_______________
_
**Please feel free to submit any and all additional information not included on the
Treatment Plan form that you feel is necessary to support the services you are requesting.**
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TREATMENT PLAN X-RAYS DIAGNOSES PATIENT’S CURRENT MEDICAL HISTORY DOCTOR PAYOR INSURED
HealthPartners Medicare/MSHO Chiropractic Treatment Review
Fax: 952-853-8713
Phone for questions: 952-883-6333