ATTACHMENT
Patient Name __________________________________
HIC# _________________________________________
D.O.S. ________________________________________
Specific Spinal Region
| CPT Code |
ICD-9 Code Region |
ICD-9 Code - DX |
| _____________ |
________________________ |
________________________ |
| _____________ |
________________________ |
________________________ |
| _____________ |
________________________ |
________________________ |
PERMANENT SUBLUXATION
Date of X-ray ______________________
Region: ___________________________
Permanent Condition ICD-9 Code __________________________________
Provider ________________________________
Provider # ______________________________