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Patient:Ins Co:WA MEDICARE-NORIDIAN Pol #:NONE <br />Date 07/29/2025Provider:Mark Shelley, DC, DACNB *** continued from previous page *** <br />Mark Shelley, DC, DACNB 08/06/2025 03:00 PM <br />Electronically Signed <br />I certify that the following supplies are medically necessary for the optimal improvement of this patient's condition: * Stick Roller, Dual Compression Ball (PNUT), Compression Ball, Oxi-Cell (Supplement), Stabilized R-Lipoic Acid (Supplement) and D3 Supreme (Supplement) <br />In addition to the following treatments, has been referred to Jean Roberto-Don, ND for an evaluation for Soundwave therapy, Bioelectric therapy, and PRP injection. <br />ORDER: Progress Examinations will be performed at 12 visit or 6-week intervals, whichever occurs soonest. <br />GOALS:1) Decrease pain to a 1 out of 10 on a 0 to 10 scale. 2) Within functional limits, restore active range of motion, strength and flexibility to the affected body regions. 3) Normal gait and gait endurance. 4) Increase tolerance to activities of daily living, recreational and occupational activities without an increase in pain or functional limitations. <br />OUTCOME MEASURES:We will utilize the following subjective and objective outcome assessment measures in order to assess patient progress and response to treatment: 1) Visual analog scale (VAS) 2) Revised Oswestry - Low Back Disability Questionnaire 3) Neck Disability Index <br />CERTIFICATION:I certify that this Plan of Care is medically necessary in order to improve the patient's condition. <br />Provider: Mark Shelley, DC DACNB NPI: 1124105275 <br />Chart Notes 6603 220th St. SW Suite 102Mountlake Terrace, WA 98043-2186Phone: (425) 774-2411Fax: (425) 672-7065 <br />Olympic Spine and Sports Therapy <br />Printed:Page 7 Of 7Tuesday, August 12, 2025 4:16:38 PM