tri medical rehab newcastle pa fax · 2013-05-20 · newcastle pa16103 800-541-0734 or fax...

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P.O. Box 550New Castle PA 16103800-541-0734 or Fax 724-658-6298

Tri Medical RehabSupply

FaxTo: From:

Fax: Pages:

Phone: Date:

Attn: Re:

Please be sure that all areas listed below are completed on the written order form sothat we are in compliance with Medical Assistance rules. Call Tri Medical at yourconvenience if you have any questions.

CJ Confirm Weight

CJ Last Exam Date

CJ Diagnosis & ICD-9 Code

CJ Refills

CJ Physician's Signature (No Stamps)

**Please note: According to Federal Medicaid regulations, only a licensed physician canprescribe DME supplies. Physician Assistants, Medical Trainees and Nurse Practitioners areno longer able to sign prescriptions. Please contact us if you would like more information onthis recent interpretation by the Department of Public Welfare.

The documents accompanying this transmission contain confidential health information that is legally privileged. Thisinformation is intended only for the use of the individual or entity named above. The authorized recipient of this information isprohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroythe information after its stated need has been fulfilled.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken inreliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify thesender immediately and arrange for the retum or destruction of these documents.

Physician Prescription for Incontinence Supplies 7112/2011

Type: New Prescription__ Renewal

Patient Information:

Adjustment __ web

Name:

Address:DOB:

Provider Information:

City:

State:

Tel:

Zip: Apt:

ID:

Tri-Medical Rehab

179 Scotland Lane

New Castle, PA 16101

**Tel: 800-541-0734 Fax: 724-658-6298**

Last Exam Date: Current Weight: [.._------------_ .. -----_._ ...._- ..-.__ .. _ ....__ ...._----------------------_._ .. _-

Step 2: Symptom (circle below)

IStep 1: Medical Necessity I

(Primary Diagnosis)*CausesType*ICD9 of Primary DX: _

or Description: •IStep 3: Refills I **(ifany)**

Refills: 1 2 3 4 5 6 7 8 9 10 11 12

Qty Product Description:

788.30 - Unspecified Incontinence788.31 - Urge Incontinence788.32 - Stress Incontinence (male)788.33 - mixed Incontinence (male) (female)788.34 - Incontinence without sensory awarenes788.35 - Post-void dribbling788.36 - Nocturnal Enuresis788.37 - Continuous Leakage788.38 - Overflow Incontinence788.39 - Other Urinary Incontinence

787.60 - Full Incontinence of Feces787.61 - Incomplete Defecation787.62 - Fecal Smearing787.63 - Fecal Urgency

Please review the above order. If the information is correct, please sign, date below and faxdirectly to our office. If any of the information IS NOT CORRECT, please make thenecessary changes, fax directly to us and we will correct our records. Please contact ouroffice at 800-541-0734 with any questions.

I certify that I am the patient's treating physician and that the medical necessity for theseitems has been met for this patient. Please fill in any missing information.

Physician's Name: (if different)

Address: City: State: Zip:

Phone: Fax: License #: NPI#

(if different) MD License #: (if different) NPI#

Printed Name:

Physician's Signature: _

Date: