YAKIMA AREA - Therapeutic Associates
YAKIMA AREA - Therapeutic Associates
YAKIMA AREA - Therapeutic Associates
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<strong>YAKIMA</strong> <strong>AREA</strong><br />
Patient Name:_____________________________________________<br />
Phone_________________________________ DOB_______________<br />
Diagnosis:_________________________________________________<br />
ICD-9_____________________________________________________<br />
r EVALUATE AND TREAT APPROPRIATELY<br />
Special Programs<br />
r ASTYM TM System<br />
r Back School Program<br />
r Lumbar Function and Stabilization<br />
r Postural/Scoliosis<br />
r Theraball<br />
r Manual Therapy<br />
r Pre-Work Hardening/Conditioning<br />
Services<br />
r Contrast Bath<br />
r Gait and Balance Training<br />
r Iontophoresis<br />
r Joint Mobilization/Manipulation<br />
r Massage<br />
r Myofascial Release<br />
r Neuromuscular Re-ed<br />
r Phonophoresis<br />
r Strain/Counterstrain<br />
r <strong>Therapeutic</strong> Exercise<br />
r Trigger Point Release<br />
r Whirlpool Bath<br />
r Other_________________________________<br />
Treat_____________________ times per week for___________________ weeks<br />
In making this referral, physician certifies that prescribed rehabilitation is medically necessary.<br />
Physician Signature_________________________________________<br />
Physician Name____________________________________________<br />
Date ______________________________________________________<br />
(REQUIRED BY MEDICARE)<br />
Thank you for this referral<br />
r WEST VALLEY PT<br />
NEW LOCATION<br />
Formerly Yakima<br />
Physical Therapy<br />
Robb Jacobs PT, DPT,<br />
Director<br />
Katie Huibregtse PT, DPT<br />
TEL: 509-453-3103<br />
FAX: 509-453-2057<br />
r SELAH PT<br />
Robb Jacobs PT, DPT,<br />
Director<br />
Katie Huibregtse PT, DPT<br />
TEL: 509-697-9109<br />
FAX: 509-697-9122<br />
Physician’s Notes:<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
_____________________<br />
PHYSICAL THERAPIST OWNED & DIRECTED<br />
RX_YAK Rev 06/18/12
www.therapeuticassociates.com/Yakima<br />
NEW Location<br />
SUMMITVIEW AVE<br />
W Naches Ave<br />
S. 76th Ave N. 76th Ave<br />
S. 74th Ave<br />
West Valley<br />
Fitness<br />
Wells Fargo<br />
W. TIETON DR<br />
S. 72ND AVE<br />
W. Chestnut Ave<br />
Rosauers<br />
Starbucks<br />
S. 70th Ave<br />
S 3 RD St<br />
Selah<br />
Family<br />
Medicine<br />
Selah<br />
Clinic<br />
W Yakima Ave<br />
S 2 ND St<br />
Pingrey<br />
Motors<br />
Office<br />
Pingrey<br />
Motors<br />
Lot<br />
S 1 ST St<br />
WEST VALLEY<br />
PHYSICAL THERAPY<br />
Robb Jacobs PT, DPT, Director<br />
210 S 72 ND Ave, Suite 130<br />
Yakima, WA 98908<br />
yakima@taiweb.com<br />
TEL<br />
FAX<br />
509-453-3103 509-453-2057<br />
SELAH PHYSICAL THERAPY<br />
Robb Jacobs PT, DPT, Director<br />
117 S 2 ND St<br />
Selah, WA 98942<br />
selah@taiweb.com<br />
TEL<br />
FAX<br />
509-697-9109 509-697-9122<br />
OBTAINING ON-LINE REGISTRATION FORMS<br />
Visit: www.therapeuticassociates.com<br />
Steps From Homepage:<br />
• Treatment<br />
• Patients<br />
• Patient Forms<br />
CAUTION: Do Not Minimize Screen While Printing! (no “fit to page” or page scaling)<br />
PLEASE NOTE: There are 5 pages to print and only the 1st page can be filled out on screen<br />
Providers for:<br />
Aetna, Crime Victims Compensation Act, Department of Social and Health Services (DSHS), First<br />
Choice Health, Great West/One Health Plan, Medicare, Molina, Non MCO Workers’ Compensation,<br />
Office of Workers’ Compensation Programs (OWCP), PIP/Auto, Premera Blue Cross (Blue Cross of WA),<br />
Railroad Medicare, Regence Blue Shield of WA, Uniform Medical Plan, Washington Labor & Industry<br />
Works Compensation (WA L&I).<br />
Provider status for other health plans may vary per office.<br />
Please phone clinic to verify insurance coverage.
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