Standard Written Physician Order

Standard Written Physician Order
Feel free to upload the patient demographic sheet from your clinic to save time. This will allow you to skip several questions as we can obtain the needed information from the clinics demographic sheet.

Please make sure the information on the demographic sheet is current.
YesNo
Patient Demographis Sheet Upload

***Use this section to upload a copy of the patient's demographic sheet OR complete the demographic information below. Take a picture with your phone or ipad then upload here.
Cancelof
Patient Name*

First NameLast Name
MaleFemale
Date of Birth

MonthDayYear
Height
Height assist our office in determining equipment sizing.
Weight
Weight is required to determine standard or bariatric equipment needs.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Patient Email
The patient will receive a copy of this order
Clinic/Physician/Nurse Secure Email
A pdf copy of this order will be emailed to this email address for your files.
Patient delivery address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Name Primary Insurance Policy #
Secondary Insurance Name Secondary Insurance Policy #
Emergency Contact Name Phone #
ICD-10 Code*
Equipment to Dispense / or / use check boxes below.
Bedside CommodeCane-StraightCane-Quad-Small BaseCane-Quad-Large BaseRollatorWalker
Hand Held Shower WandShower Chair (not covered by Ambetter - we suggest a transfer bench)Tub Grab BarTub Transfer Bench
YesNo
Seat & Back Wheelchair CushionStandard up to 250lbsLightweight up to 300 lbs (ADD to chart notes=patient cannot self-propel a standard but can and does propel a lightweight)Heavy Duty 250-300lbsExtra Heavy Duty 300-700lbsElevating Leg RestOxygen Tank HolderTransfer Board up to 440lbs
Hospital Bed with Therapeutic Mattress - chart notes requiredLow Air Loss Wound Mattress - must have documented staged wounds on trunk - chart notes required.Manual Hoyer LiftTrapeze Bar
YesNo
What MDI therapy has the patient tried & failed?*
The MDI must be tried and failed (prior) to dispensing the nebulizer.
What RX is being prescribed for the nebulizer and how often?*
McKesson Nebulizer
Serial #*
YesNo
Diapers (Briefs)PullupsBed/Chair PadsUnderwear LinersGlovesWipes (1 complimentary package)
YesNo
How many cans of boost per day? 1 2 3 or 4
For Medicaid beneficiaries ages 5-20 years old. Max units per day is 4. Each can is 240 calories.
YesNo
How many packets of thickener per day?
For Medicaid beneficiaries of any age. Max is 16 units per day
HoneyNectar
Physician Signature*

Clear
NPI #*
Upload most recent chart note (optional) if required for insurance purposes we will reach out at that time.

Cancelof
Date

MonthDayYear
Date
Please have patient opt-in to text message and Sign at the bottom
AUTHORIZATION TO ASSIGN BENEFITS TO PROVIDER and PROOF OF DELIVERY FOR FIRST MONTH SET UP OF DIABETIC SUPPLIES and/or NEBULIZER (if ordered)
I hereby request payment of my authorized carrier to be made on my behalf to Medical Solutions of Arkansas, LLC for current and reoccurring products and services they provide me. I further authorize a copy of this agreement to be used in place of the original and authorize any holder of information about me including, but not limited, to Medical Records to release such Information to Medical Solutions of Arkansas, LLC and Health Care Finance Administration, any other insurance and/or their agents any information to determine these benefits. Medical Solutions of Arkansas, LLC may bill third party payers as a courtesy, when appropriate. I understand that I am fully responsible for all deductibles, coinsurance and non-covered items. I consent to treatment from Medical Solutions of Arkansas and have been trained on the proper use of the items prescribed/delivered.
YesNo
Patient or Caregiver Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Standard Written Physician Order

Please have patient opt-in to text message and Sign at the bottom