Required Information For Inpatient Lymphedema Treatment Referral
ADVERTISEMENT
1
2Required information for Inpatient Lymphedema Treatment Referral
*Please send ALL information as complete packet
Including THIS face sheet to the address below
Siskin Hospital Lymphedema Clinic
You can also contact me at:
1 Siskin Plaza
phone: (423) 634-1246
Chattanooga, TN 37403
fax:
(423) 634-4546
Attn: John Jordi
e-mail:
Medical information required for evaluation or screening
1.
ALL Insurance information (copy of card(s) - primary, secondary, supplemental)
2.
Prescription from current physician for inpatient lymphedema program
3.
Name and phone number of primary care physician for follow up
4.
Summary of past medical history from primary care physician
5.
Therapy notes from last lymphedema program attended
6.
Lab and diagnostic test results including:
a. Recent ECHO and cardiac information
b. Recent Nephrology information (tests and labs)
7.
List of medications and allergies
8.
Current and accurate height and weight HEIGHT:_________ WEIGHT:____________
Photos (in undergarments) from all 4 sides
9.
Post Treatment (self care at home)
1.
Pt. able to manage reduction including:
a. Donn, doff garments and bandages
b. If a family member used then they must be able to provide for anticipated needs (see pg 2)
2.
Name and phone numbers of care givers (see pg 2)
3.
Therapy center for outpatient follow-up (see pg 2)
4.
Pt. to show long-term potential for improvement and independence
Medical and financial requirements
5.
Pt. has physical deficits including ADL limitations (see pg 2)
6.
Pt. agrees to any financial obligations not covered by insurance (see page 2 for signature)
7.
Signed Advanced Beneficiary Notice (ABN) for Medicare applicants (call to request form)
**Medicare does not cover Bandages or Garments (DME).
*Grant request is available upon request. If you need to apply please call me directly.
Therapy and personal goals
8.
Pt. to be Stage 3, Elephantiasis size
9.
Pt. needs to tolerate 3 or more hours of therapy including:
a. Bandaging, MLD, ther. ex, rolling and washing bandages. Pt. safe to walk or get to therapy
and shower independently (or bring assistance)
10.
Personal goals and reasons for entry to in-patient program (see pg 2)
11.
Agreement to 4 weeks of inpatient therapy
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical