Maternity Physician RX Order

Patient Name*

First NameLast Name

Birthdate*

Date

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Phone Number*

Secondary Phone Number

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Insurance ID#*

Due Date

Date

Height

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Maternity Supplies*

Professional Grade LSO Maternity Belt Product Image

Professional Grade LSO Maternity BeltHCPCS: L0642, Diagnosis: Lower Back Pain During Pregnancy (ICD-10: O26.89/M54.5) Plan of Care: To provide spinal support and alleviate lower back pain. Instructions for Use: Wear as needed during physical activities to support the lower back. Follow fitting instructions for optimal benefit. Duration: One year postpartum

$ Free Quantity

Hospital Grade Breast Pump Product Image

Hospital Grade Breast PumpHCPCS: E0603+A4287, Diagnosis: Encounter for Lactating Mother (ICD-10: Z39.1) Plan of Care: To be used for expressing breast milk to support breastfeeding. For safe storage of expressed breast milk. Instructions for Use: Use as needed to express milk; follow manufacturer's guidelines for safe operation. Duration: One year postpartum

$ Free Quantity

Compression StockingsHCPCS: A6530 x2, Diagnosis: Edema in Pregnancy (ICD-10: O12.00) Plan of Care: To reduce leg swelling and improve circulation during and after pregnancy. Instructions for Use: Wear daily, especially during prolonged standing or sitting. Follow care instructions for proper maintenance. Duration: One year postpartum.

$ Free Quantity

Wrist Spica SupportHCPCS: L3809 x2, Diagnosis: Carpal Tunnel Syndrome, Unspecified Upper Limb (ICD-10: G56.00) Plan of Care: To reduce pain and discomfort related to carpal tunnel syndrome during pregnancy. Instructions for Use: Wear as needed, especially during activities that exacerbate symptoms. Follow the manufacturer's instructions for proper fitting. Duration: 1 year

$ Free Quantity

Automatic Blood Pressure Monitor Product Image

Automatic Blood Pressure MonitorHCPCS: A4670, Diagnosis: Essential (Primary) Hypertension (ICD-10: I10) Plan of Care: To monitor and manage the patient’s blood pressure during pregnancy to prevent complications, ensuring maternal and fetal well-being. Duration: One year postpartum.

$ Free

Mamila Milk Bags 200ctHCPCS: A4287 x200, Diagnosis: Encounter for Lactating Mother (ICD-10: Z39.1) Plan of Care: To be used for expressing breast milk to support breastfeeding. For safe storage of expressed breast milk. Instructions for Use: Use as needed to express milk; follow manufacturer's guidelines for safe operation. Duration: One year postpartum.

$ Free

总计

$0.00

Maternity Supplies

Ordering Provider Name*

Npi Number*

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Office Manager - Location*

Offices with multiple locations please add which location we should contact.

OFFICE VISIT NOTES

Maternity Physician RX Order

MEDICAL RECORDS REQUEST