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RYKE GETS RESULTS

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					                                                                           NORTHEAST - Pool Therapy
                                                                           12413 Judson Rd., Suite 260
                                                                           T 210-656-RYKE (7953)
                                                                           F 210-656-7957
                                                                           Located across from the
                                                                           Northeast Methodist Hospital
                                                                           parking lot.

SOUTHEAST - Pool Therapy             SOUTHWEST                             MEDICAL CENTER - Pool Therapy
3875 E. Southcross, Suite B          3110 Nogalitos, Suite 201             2140 Babcock Rd., Suite 130
T 210-337-RYKE (7953)                T 210-534-RYKE (7953)                 T 210-614-RYKE (7953)
F 210-337-7966                       F 210-534-6695                        F 210-614-4190
Minten Plaza between Pecan           Duncan Professional Building          Babcock Medical Centre
Valley Golf Course and               between S. Zarzamora and              between Wurzbach and Louis
Southeast Baptist Hospital.          HWY 90.                               Pasteur.

Patient Name:                                                                 Date:
Telephone#:                                                        DOB:
Diagnosis:

Frequency:         † 5x week          † 4x week           † 3x week          † 2x week          † 1x week
Duration:          † 8 weeks          † 6 weeks           † 4 weeks          † 3 weeks          † 2 weeks
Precautions:

† Consult: Evaluate & Treat
Goals:     † Increase R.O.M               † Decrease Pain            † Establish Home Exercise Program
           † Increase Strength            † Decrease Edema           † Improve Function
           † Increase Endurance           † Return to Work           † Other

Therapeutic Exercise/Programs                             Industrial Rehabilitation
 †   Aquatic Therapy                                       † Work Conditioning
 †   McKenzie Program                                          (Includes Pre & Post FCE)
 †   Flexion Program                                       † Work Hardening
 †   Functional Stabilizing Program                            (Includes Pre & Post FCE)
 †   Physical Conditioning                                 †   Back School/ Body Mechanics Training
 †   Codman Exercises                                      †   Injury Prevention Program
 †   NDT/PNF                                               †   Functional Capacity Evaluation (FCE)
 †   Pilates/Core Stabilization                            †   Impairment Rating
 †   Hand Therapy Program                                 Modalities
 †   Pregnancy (Pre/Post Natal)                            †   Ultrasound
 †   Passive/Active R.O.M./Strengthening                   †   Electrical Stimulation
 †   TMJ Dysfunction & TMD                                 †   Neuromuscular Re-Education
 †   Vestibular Rehab                                      †   Gait Training
 †   Balance Rehab                                         †   Iontophoresis/Phonophoresis
Manual Therapy                                             †   TENS (Rental/Purchase)
 †   Soft Tissue Mobilization                              †   Hydrotherapy/Whirlpool
 †   Joint Mobilization                                    †   McConnell Taping
 †   Manual Stretching                                     †   Orthotics
 †   Manual Traction                                       †   Mechanical Traction, Cervical & Lumbar
 †   Muscle Energy Technique
 †   Positional Release


Additional Instructions:



Follow-up appointment with Physician:
I certify the above treatment plan is medically necessary and approved by me.

Physician:
Signature:                                                         Date:
                                       www.rykept.com
                                   “RYKE GETS RESULTS”
                                    Please Fax to
210-337-7966 (SE) • 210-534-6695 (SW) • 210-656-7957 (NE) • 210-614-4910 (Medical Ctr)
DO NOT EMAIL PRESCRIPTION The electronic prescription form is provided for your convenience. With
respect to responding to this form, please do not send the prescription via email. Please populate, print and
sign a hardcopy that may be faxed, mailed or hand delivered to the clinic.
                                                                     NORTHEAST - Pool Therapy
                                                                     12413 Judson Rd., Suite 260
                                                                     T 210-656-RYKE (7953)
                                                                     F 210-656-7957
                                                                     Located across from the
                                                                     Northeast Methodist Hospital
                                                                     parking lot.

SOUTHEAST - Pool Therapy          SOUTHWEST                          MEDICAL CENTER - Pool Therapy
3875 E. Southcross, Suite B       3110 Nogalitos, Suite 201          2140 Babcock Rd., Suite 130
T 210-337-RYKE (7953)             T 210-534-RYKE (7953)              T 210-614-RYKE (7953)
F 210-337-7966                    F 210-534-6695                     F 210-614-4190
Minten Plaza between Pecan        Duncan Professional Building       Babcock Medical Centre
Valley Golf Course and            between S. Zarzamora and           between Wurzbach and Louis
Southeast Baptist Hospital.       HWY 90.                            Pasteur.




We accept the following Insurances:
• Advantra Freedom                                  •   Integrated Health Plan
• Aetna US Healthcare, PPO, HMO,                    •   LOP Letters of Protection
  Medicare, Medicaid                                •   Mail Handlers Benefit Plan
• Amerigroup Medicaid                               •   Medicaid, Traditional, Community First, Supe-
• Beech Street                                          rior, Molina, Amerigroup, Aetna
• Benefit Planners PHA                              •   Medicare Traditional, Railroad
• BlueCross/BlueShield, PPO, HMO                    •   Molina Medicaid, Medicare
• Bravo by Elderheath                               •   National Health Care Alliance
• Care Improvement Plus                             •   One Health Plan
• CCN                                               •   PHCS
• Champ VA                                          •   PIP Auto Insurance
• CHIPS (Community First, Superior)                 •   Pacificare
• Cigna, PPO, HMO                                   •   San Antonio Employers Health Alliance
• City of San Antonio Employees                     •   Smart Comp Network
• Community First, PPO, HMO, Medicaid               •   South West Medical Provider Network
• Corvel                                            •   Superior Medicaid
• Department of Labor                               •   Texas Star Network
• Direct Care                                       •   Texas True Choice
• Elderhealth                                       •   Tricare
• First Health Network                              •   Unicare/Affiliated Healthcare
• Galaxy Health Network                             •   Union Pacific Railroad
• Greatwest Healthcare                              •   United Healthcare
• Harrington Benefit Services                       •   USC Health Services
• Health Payors Org.                                •   VA
• Humana, PPO, HMO, Gold Classic, Medicare          •   WellCare, Open Access
  PPO, Choicecare, Military                         •   Workers Compensation (All)

If your insurance is not listed, please call any of our locations and we will verify your benefits.
                                    www.rykept.com
                                “RYKE GETS RESULTS”
                                    Please Fax to
210-337-7966 (SE) • 210-534-6695 (SW) • 210-656-7957 (NE) • 210-614-4910 (Medical Ctr)

				
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