Acupuncture Referral

Integrated Acupuncture & Herbs, Inc. (Westlake) Integrated Acupuncture & Herbs, Inc. (Los Angeles)
890 Hampshire Road, Suite # S 2001 S. Barrington Ave, Suite #111
Westlake Village, CA 91361 Los Angeles, CA 90025
Phone: 805.379.1108 Phone: 310.882.9770
Fax: 805.379.2779 Fax: 310.914.9031

Patient ______________________________Date: _________Referring Physician_______________________________

Next PTP follow up visit__________Diagnosis___________________________________________________________
Areas to be treated:
J C-Spine
J T-Spine
J LS-Spine
J Shoulder (L / R / B)
J Elbow (L / R / B)
J Wrist (L / R / B)
J Hand (L / R / B)
J Hip (L / R / B)
J Knee (L / R / B)
J Ankle (L / R / B)
J Foot (L / R / B)
J Other_______________

Factors delaying patients recovery:
J Chronic condition J Patient is de-conditioned J Continuance of perpetuating factors: patient continues with same job
activities J Not participating in a multidisciplinary program J Flare-up(s) _______________________________________
J Patient not responding to other Pain Management treatments ___________________________________________
J Co-Morbidity Factors _____________________________________________________________________________
J The patient is currently participating in a multidisciplinary program with:
J Pool Therapy J Chiropractic J Physical Therapy J Exercise Program J Other_______________________________

Acupuncture treatment requested: combine electric-acupuncture, heat, myofascial release, etc. (passive care)
with an exercise program (active care) as needed, to avoid de-conditioning and dependency on the use of
passive modalities.

Treatment Frequency J new patient J different area J 2x3 (as a trial) if improvement is obtained, continue (2x3)
J continuation of care J 1X6 or other J _____x_____

Acupuncture treatments completed in 20__ :_____
____________________________________________________________________________________________________________
Acupuncture medical treatment guidelines - State of California 2007
The acupuncture medical treatment guidelines (MTUS: CA UR regs. 9792.20-23) shall supersede the text in the ACOEM
Practice Guidelines, second edition, relating to acupuncture.
Definitions:
(A) Acupuncture is used as an option when pain medication is not reduced or not tolerated, it may be used as an adjunct to
physical rehabilitation and/or surgical intervention

(B) Indications for acupuncture/with electrical stimulation include the following presenting complaints in reference to the
following ACOEM practice guidelines chapter headings:J neck and upper back complaints, J elbow complaints, J forearm,
J wrist, and J hand complaints, J low back complaints, J knee complaints, J ankle and foot complaints; pain, suffering,
and the restoration of function

(C) Frequency and duration of acupuncture or acupuncture with electrical stimulation may be performed as follow: time to
produce functional improvement: up to 6 treatments

(D) Acupuncture treatment may be extended if functional improvement is documented

Be aware of the CA UR regulations and penalties: If more information is needed-requested, the physician to be contacted should be the
one providing-requesting the acupuncture services (requesting physician) and not the referring physician (PTP). 9792.9(1) If reasonable
information is requested, it should be within 5 working days (prospective-concurrent reviews) and 30 days (retrospective reviews). Some
others: 9792.6(q), (s), 9792.7(b) (1), (2), 9792.8(a) (1), 9792.9(3), (4), (c), (f), (l), 9792.10(1), (2)