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I control My Pain Po box 110487 Brooklyn NY 11211 Phone 1888 267 3631 Fax 1888 718 9898 PRESCRIPTION FORM –LETTER OF MEDICAL NECESSITY AND DOCTOR NOTES Patient name: __________________________________________________________________ Diagnosis (ICD-9) 1. _______ 2. _______ 3. ______ 4. ______ Device Prescribed: ____ TENS / Supplies Symptoms: ____________________________________________________________________ Prognosis: ____ Excellent ____Good ____Fair _____ Guarded Date First Diagnosed: ____________ Date Last Seen: __________________ Area (s) to be treated: ___________________________________________________________ Previous Treatments Rendered: ____Manipulation ____Massage Therapy ____ Surgery ____Heat/Ice Treatment ____Physical Therapy ____Medication: ____________________ ____ Other: _____________________ I certify that the above prescribed equipment, supplies and accessories provided by I control My Pain, are medically necessary as part of my treatment plan for this patient’s condition as stated above, I have initiated a trial use of the indicated equipment in my office and have found it to be effective. This prescription is valid for one year from the date indicated below unless otherwise noted. ________________________________ ________________________________ Physician’s Signature Date (Please print below) Physician’s Name: _______________________________ License/ UPIN #: ______________ Address: ______________________________________________________________________ Telephone #: _____________________________ Fax #: _______________________________
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