Bhsf Form Dip1 Prescription Request Form For Disposable Incontinence Products

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Revised BHSF Form DIP1
Issued 10/15
PRESCRIPTION REQUEST FORM FOR DISPOSABLE INCONTINENCE PRODUCTS
Recipient Information
Name: _______________________________________________ Date of birth: ___________ Age: __________
Medicaid ID: ___________________________________________Height: ____________ Weight ____________
Recipient’s Address __________________________________________________________________________
Prescribing Provider:
Prescriber’s Name: ______________________________________________ Phone #: ___________________
Address: _______________________________________________________Fax # ______________________
Medical Diagnoses causing the urine and/or fecal incontinence :
Primary:
Secondary:
________________________________________
__________________________________________
Specify Urine/Fecal incontinence diagnoses :
Primary:
Secondary:
________________________________________
__________________________________________
Mobility
Ambulatory
Minimal assistance ambulating
Transfer Assistance
Confined to bed or chair
Extraordinary Needs
Supporting documentation for acute medical condition and/or extenuating
circumstances for incontinence products (more than six per day).
Mental Status/Level of Orientation
Frequency of anticipated change
Has the ability to communicate needs
During Day time (6 AM-10PM) every _________ hrs.
Sometimes communicates needs
During Night time (10PM – 6 AM) every _______hrs.
Unable to communicate needs
Confined to bed or chair
Additional supporting Diagnoses
Indicate current supportive services
Home Health
_________________________________________
Skilled Nursing Services
_________________________________________
Personal Care Services
Other __________________________
Specify incontinence supply, size,
Comments
quantity/24 hours and duration of need:
______________________________________________
___________________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
By my signature I attest that I have seen the patient and the item prescribed is
medically necessary. I have personally completed this request and a copy will be
______________________________________________
maintained in the patient’s medical record.
______________________________________________
Prescriber’s Signature:
______________________________________________
_________________________________________
Additional documentation attached
Date:
_________________________________________

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