Prescription / Certificate Of Medical Necessity

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PRESCRIPTION / CERTIFICATE OF MEDICAL NECESSITY
Optimax S4000 (IFC, NMES)
J-Wave (NMES)
Comfort Wave (IFC, NMES)
J-Stim (Hi Volt/Joint Stim)
Patient Information:
Name: __________________________________________
Address: ________________________________________________________
Date of Birth: _________/_________/__________
________________________________________________________________
Gender:
Male
Female
Effective Date: ___________________________________________________
LON / Duration:
Rental: _______ (1-99 Month Period)
Purchase
Supplies:
Lead Wires –
Rechargeable Batteries – 4/Month
Disposable Batteries –
1 pkg Monthly
1pkg Monthly
A/C Wall Adapter
Battery Charger
Conductive Mist –
1 Bottle Monthly
Skin Barrier Wipes –
Protective Pouch w/Clip
Thera Cream Lotion –
24 wipes Monthly
1 Bottle Monthly
Electrodes:
Medical Necessity for 4 Leads (2 Channels) vs. 2 Leads (1 Channel)
____
4 Electrodes are needed to surround and
2 Packs Monthly
treat a large pain area
4 Packs Monthly
____
4 Electrodes are needed to treat two different
6 Packs Monthly
areas
____
4 Electrodes are needed to utilize a crossed
A4595 - Supply Kit
interferring stimulation pattern
Garments:
Medical Necessity for a 4 Lead electro-mesh garment
____
Treatment Site is inaccessible to
Cervical
Hand/Wrist
place disposable electrodes
Shoulder
Elbow
____
Skin Sensitivity or skin type
Upper/Mid Back
Knee
____
Garment is needed to surround a large
Low Back
Foot/Ankle
treatment area
OTHER: ________________________________
____
Additional Support is needed
Replacement Every 6 Months
____________
___________
____________
____________
Diagnosis:
ICD.9 CODE
ICD.9 CODE
ICD.9 CODE
ICD.9 CODE
Medical Necessity: (Indications for Use)
Muscle Disuse Atrophy
Muscle Spasms
Chronic/Acute Pain
Comments: ______________________________________________________________________________________________
Physician Information: (PLEASE PRINT)
First Name: _____________________________ Last Name: ____________________________ NPI # : _____________________
Address: ________________________________________________________________________________________________
City: _____________________________________
State: ___________
Zip: ____________________
D.A.W.
Phone (_______) ________-______________
Fax (_______) ________-______________
PHYSICIAN SIGNATURE
___________________________________________
Date ___________________________
*Stamped Signatures are NOT Accepted!*
Advanced Therapy Concepts
Phone (800)864-0293 Fax (616)772-9368

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