Medical Clearance Form - Indiana Health Coverage Programs
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2I n d i a n a H e a l t h C o v e r a g e P r o g r a m s
M E D I C A L
C L E A R A N C E
F O R M
H O S P I T A L
A N D
S P E C I A L T Y
B E D S
Section A
Certification Date:
Initial: ____________
Revised: __________
Patient Name:
Supplier Name:
Address:
Address:
Phone Number:
Phone Number:
RID Number:
Provider Number:
Place of Service:
HCPCS Code:
PT DOB_________; Sex___(M/F) HT______(IN);
_______________
WT______(LBS)
Name and address of
Physician Name:
facility (if applicable)
Address:
Physician UPIN Number: ____________
Physician Phone Number: ___________
Section B
*Information in this section may not be completed by the supplier of the items or supplies
Estimated. length of need (number of months_______)
DX codes (ICD) ______ ______ _____ _____
Years_______ Lifetime_______
Check Y for Yes, N for No, or NA for Not Applicable for the following questions:
1. Does the patient require positioning of the body in ways not feasible with an ordinary bed
Y
N
NA
due to a medical condition which is expected to last at least one month?
2. Does the patient require, for the relief of pain, positioning of the body in ways not feasible
Y
N
NA
in an ordinary bed?
3. Does the patient require the head of the bed elevated more than 30 degrees most of the
Y
N
NA
time due to congestive heart failure, chronic pulmonary disease or aspiration?
4. Does the patient require traction that can only be attached to a hospital bed?
Y
N
NA
5. Does the patient require a bed height different than a fixed height hospital bed to permit
Y
N
NA
transfers to chair, wheelchair or standing position?
6. Does the patient require frequent changes in body position and/or have an immediate need
Y
N
NA
for a change in body position?
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Medical Clearance Form for Hospital and Specialty Beds
Version 2.0, June 2014
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Parent category: Medical