Name of Referring Physician:
Address:
City:
State:
Zip code:
Telephone Number:
Fax Number:
   
 
Patient Name:
Date of Birth:
(sample 1970)
SSN:
Address:
City:
State:
Zip code:
Telephone Number:
Alternate Phone Number:
Date of Return/Next Appointment:
Date of Injury:
Diagnosis:
   
 
IF-Interferential/Stim. unit for home use
Galvanic Stimulator
Portable Cold Therapy
Brace
Therapeutic Shoe
CPM
   
 
PPO PI Lien
PI w/ Med. pay W/C W/C Lien Cash
Insurance Company:
Address:
City:
State:
Zip code:
   
 
Claim:
WCAB#:
Adjuster's Name:
Telephone Number:
Ext:
Employer:
Work phone Number:
Ext:
   
 
Attorney Name:
Address:
City:
State:
Zip code:
Telephone Number:
Fax Number:
   
 
 

P.O. Box 1831
La Mirada, Ca 90637-1831
(714) 547 4747
. . . (714) 547 4877 Fax

Toll Free
1 (888) 632 98 32
. . . 1 (866) 632 98 32 Fax

info@meditechsolutions.com

 
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