Physician Progress Note Page 4


Diamond Medical Equipment
1324 N. Farrell Court 102, Gilbert AZ 85233
480.926.4363 FAX 480.926.4364
Items Needed for Durable Medical Equipment to be dispensed
Date of Order
Dr. Name
Dr. NPI #
Pt. Name
Detailed Description of Equipment
Length of Need
Start Date
Dr. Signature w/ Signature Date
2. Face Sheet
3. H & P
4. Progress Notes
5. Face to Face visit from Physician
If done by a N.P. or P.A. needs to be countersigned by a M.D. or D.O.
See attached for LCD language for F2F progress note.
Can NOT be written on a Dr. order.
Must be dated/written prior or same day to the order written.
6. CMN for Oxygen. Sent to Dr to fill in LON, Dianosis codes, section b, sign and Date, then fax back to
Diamond Medical
Please note for Oxygen, sats need to be done 48 hrs to discharge from a facility, or 30 days prior to order if
taken in outpatient setting.


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