Jamie Freeman

 
 Zurich Services Corporation  
 CONFIDENTIAL 
 16-11-08
 TOWER PHYSICAL THERAPY INC 
 Extension Notice 
 Claimant: Jamie Freeman 
 Requesting MD: Dr Loretta Henderson MD 
 Claim Number: 2016201611601 
 DOB: 86-10-08 
 DATE OF INJURY: 19-06-27  
 Place of Service: Tower Physical Therapy Inc 
 We have certified the treatment(s) listed below: 
 Additional Services Certified: 
 PT R Ankle 
 Certification Period: 
 10/21/2011 - 12/26/2011 (6 Visits ) 
 Certification Number: 
 116016-221673-161 
 If additional treatment and/or additional time is required, please contact us at (816) 416-8161 
 Zurich Services Corporation 
 MCSC - Utilization Review Unit 
 Page 1 of 3 
 Doc Type: Utilization Review 
 Doc: UR-11 
 Doc Description: UR Decision LetteCE 
 Reference: 20161016FOSTER3166 
 Rev. 03/31/2009 
 000036 
 0036
