Schreiber Lumbar Brace
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Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
Kimberly Schreiber
Patient Name:
Patient Date of Birth
Patient Address
Patient Phone (Auto or W/C) Claim # (Auto or W/C) Date of Accident
Patient Data & Lien
Insurance Co.
Insurance ID #
Insurance Phone
Group # Insured's Name
Patient Agreement
hereinafter referred to as *The Company, will be the supplier. I understand that this equipment is to be used for my diagnosed condition and is issued under a doctor’s prescription. I absolve The Company of responsibility as a result of any accident or injury caused directly or indirectly while using the equipment. I authorize The Company to provide supplies as needed. I authorize the release of medical records to The Company in order to determine benefits and to assist in correspondence with any third parties regarding collections of benefits on my behalf. I authorize payment of medical benefits directly to The Company. A copy of this authorization is as valid as the original. I understand that The Company is HIPAA compliant and will protect my privacy with regard to my medical and personal information. I acknowledge receipt of “Notice of Privacy Practices and CMS Medicare DMEPOS SUPPLIER STANDARDS”. By my signature below, I am acknowledging receipt of this equipment.
Patient Signature
Date
Serial #
Physician Notes / Previous Treatments / Letter of Medical Necessity
Equipment Prescribed : (
)
TENS / EMS unit Purchase
(
) E0855 Cervical Traction Device
(
)
Supplies for TENS/EMS
(
) Water Circul. heat/cold pump w/pad
L0631 Lumbar Brace
(
) Pad for water circulation heat unit
Other
(
) Conductive Brace / Wrap / Garment
X (
)
Lumbar
Knee
Ankle
Recommended Usage: Period :
Area to be treated
Prognosis
ICD ( Codes Applicable)
Excellent
Good
Fair
Guarded
Area to be treated Previous Treatments Pain Severity
Chronic Mild
Severe
Intractable
Moderate
Date First Diagnosed
Symptoms:
Date Last Seen
I certify that the above prescribed equipment, as provided by The Company is both reasonable and medically necessary as part of my treatment plan for this patient's condition as stated herein. This prescription is valid for one year from the date indicated unless otherwise noted. I authorize no substitute for the equipment prescribed. PO Box 550747 Physician's Signature
Date
Address
Atlanta
GA
30355
Dr. Alesia Reynolds
City
State
Zip Code
Printed Name
404-477-1797
404-477-1897
Phone
Fax
NPI
1
Patient Data / Script
Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
1
Patient Data / Script
866-633-6261
866-633-6262 fax
Kimberly Schreiber
Patient Name:
Patient Date of Birth
Patient Address
Patient Phone (Auto or W/C) Claim # (Auto or W/C) Date of Accident
Patient Data & Lien
Insurance Co.
Insurance ID #
Insurance Phone
Group # Insured's Name
Patient Agreement
hereinafter referred to as *The Company, will be the supplier. I understand that this equipment is to be used for my diagnosed condition and is issued under a doctor’s prescription. I absolve The Company of responsibility as a result of any accident or injury caused directly or indirectly while using the equipment. I authorize The Company to provide supplies as needed. I authorize the release of medical records to The Company in order to determine benefits and to assist in correspondence with any third parties regarding collections of benefits on my behalf. I authorize payment of medical benefits directly to The Company. A copy of this authorization is as valid as the original. I understand that The Company is HIPAA compliant and will protect my privacy with regard to my medical and personal information. I acknowledge receipt of “Notice of Privacy Practices and CMS Medicare DMEPOS SUPPLIER STANDARDS”. By my signature below, I am acknowledging receipt of this equipment.
Patient Signature
Date
Serial #
Physician Notes / Previous Treatments / Letter of Medical Necessity
Equipment Prescribed : (
)
TENS / EMS unit Purchase
(
) E0855 Cervical Traction Device
(
)
Supplies for TENS/EMS
(
) Water Circul. heat/cold pump w/pad
L0631 Lumbar Brace
(
) Pad for water circulation heat unit
Other
(
) Conductive Brace / Wrap / Garment
X (
)
Lumbar
Knee
Ankle
Recommended Usage: Period :
Area to be treated
Prognosis
ICD ( Codes Applicable)
Excellent
Good
Fair
Guarded
Area to be treated Previous Treatments Pain Severity
Chronic Mild
Severe
Intractable
Moderate
Date First Diagnosed
Symptoms:
Date Last Seen
I certify that the above prescribed equipment, as provided by The Company is both reasonable and medically necessary as part of my treatment plan for this patient's condition as stated herein. This prescription is valid for one year from the date indicated unless otherwise noted. I authorize no substitute for the equipment prescribed. PO Box 550747 Physician's Signature
Date
Address
Atlanta
GA
30355
Dr. Alesia Reynolds
City
State
Zip Code
Printed Name
404-477-1797
404-477-1897
Phone
Fax
NPI
1
Patient Data / Script
Prescription Form-- Letter of Medical Necessity Physician notes, previous treatments
866-633-6261
866-633-6262 fax
1
Patient Data / Script
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