Huey's Home Medical, Inc.

Bed 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

DOB*

Sex

Attach Demographic Sheet

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Height*

Feet

Height*

Inches

Weight*

Pounds

Diagnosis*

Order Date*

Length of Need

Months (99 = Lifetime)

Hospital Bed

Hospital Bed Types*

Semi-Electric (E0260) Full Electric (E0265)

Please note patient insurance coverage differs for full electric beds. Most insurers consider the functionality of a full electric bed as a convenience. If a patient qualifies for a semi-electric bed per their Insurance guidelines, an out of pocket upgrade may be available.

Accessories

Patient Lift with Sling (E0630) Fixed Trapeze Bar (E0910) Free-Standing Trapeze Bar (E0940)

Below are non-covered items and offered as private pay.

Over-the-Bed Table Sheet Set Fitted Sheet Pillow Wedge

Please include chart notes indicating medical necessity for equipment ordered.

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Anticipated Date of Discharge

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*