Cooney Medical Inc. - Group 2 Support Surfaces Order Form

Cooney Medical Inc.

Group 2 Support Surfaces Order Form

Patient Name*

First Name

Last Name

Patient Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Patient Phone Number*

Primary

Patient Phone Number

Alternate

Social Security Number

Primary Insurance

Insurance Name

Primary Insurance

Insurance ID Number

Secondary Insurance

Insurance Name

Secondary Insurance

Insurance ID Number

Date of Birth*

Sex

Attach Demographic Sheet

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Height*

Feet

Height*

Inches

Weight*

Pounds

Diagnosis*

Order Date*

Length of Need

Months (99 = Lifetime)

E0277 - Low Air Loss Mattress

Supplier's Charge $

To be completed by the supplier.

Medicare Fee Schedule Allowance $

To be completed by the supplier.

The information below may not be completed by the supplier or anyone in a financial relationship with the supplier.

Indicate which of the following conditions describe the patient. Check ALL that apply.

1. Does the patient have multiple stage ll pressure ulcers on the trunk or pelvis?

Y N D

2. Has the patient been on a comprehensive ulcer treatment program for at least the past month which has included the use of alternating pressure or low air loss overlay which is less than 3.5 inches, or a non-powered pressure reducing overlay or mattress?

Y N D

3. Over the past month, the patient's ulcers have 1) improved; 2) remained the same; or 3) worsened?

Y N D

4. Does the patient have large or multiple stage lll or IV pressure ulcer(s) on the trunk or pelvis?

Y N D

5a. Has the patient had a recent (within the past 60 days) myocutaneous flap or skin graft for a pressure ulcer on the truck or pelvis?

Y N D

5b. If yes, give the date of surgery.

6. Was the patient on an alternating pressure or low air loss or bed or air-fluidized bed immediately prior to a recent (within the past 30 days) discharge from a hospital or nursing facility?

Y N D

* If none of the above applies, please attach a separate sheet documenting medical necessity for the item ordered.

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Physician's NPI #*

Physician's Name*

First Name

Last Name

Referral Contact Name

First Name

Last Name

Referral Contact Phone Number

Physician's Signature*

[clear]

Use your mouse or finger to draw your signature above.

By my electronic signature above, I confirm the above referenced patient is being treated by me and has been seen and evaluated by me within ninety (90) days of this Written Order. All of the information contained in this Written Order accurately reflects the patient’s diagnosis and the treatment regimen I have prescribed. The medical records for this patient substantiate the medical necessity of the prescribed items. It is my intent, this electronic signature has the same force and effect as a written document.

Date Signed*