Physician's DME Standard Written Order/Prescription Form

1
Patient name* This field is required.Patient Name
Name
2
Patient's Street AddressStreet Address
Address
3
Patient's City, State, Zip codePlease enter patients city, state and zip code
4
Patient's Phone
Area Code
Phone Number
5
Patient's Date of Birth* This field is required.
Date
Month
Day
Year
6
DIAGNOSIS 1* This field is required.Please provide Diagnosis Code
7
DIAGNOSIS 2* This field is required.Diagnosis
8
DIAGNOSIS 3
9
DIAGNOSIS 4
10
EFFECTIVE DATE of Order* This field is required.Date of Prescription
Date
Month
Day
Year
11
LENGTH OF NEED
99 months
12
Frequency
One time
13
HCPCS Code
E0484
14
DESCRIPTIONEMST75 Lite positive expiratory pressure device
EMST75 Positive Expiratory Pressure Device
15
I, the undersigned, certify that the above prescribed equipment/supplies is medically necessary as part of my treatment for this patient. In my opinion, the equipment prescribed is reasonable and necessary for accepted standards of medical practice and treatment of this patient's condition and has not been prescribed as "convenience equipment".
16
Physician's Signature
Clear
17
Date* This field is required.Today's Date
Date
Month
Day
Year
18
PHYSICIAN'S NAME* This field is required.
19
NPI NUMBER* This field is required.Please provide your NPI number
NPI number
20
Phone* This field is required.Office Phone
Area Code
Phone Number
21
FaxOffice Fax
22
Contact Email Address* This field is required.Where should we send a copy of this form?
example@example.com
Should be Empty: