Physician Prescription Order

Pleural & Peritoneal Drainage Supplies
Physician's Written Order
QUESTIONS? Contact A Patient Representative at McCormick Medical
Phone: (425) 778 - 4421 Fax: (425) 776 - 2433
E-Mail: asept@mccmed.com
All field are required to process an order.
Start Date

MonthDayYear
Date
PATIENT
First
Last
MI
D.O.B.

MonthDayYear
Date
Gender

MFN/A
E-Mail Address
example@example.com
Street Address
Phone #
City
State
Zip
Alternative Patient Contact
Alternative Contact Phone #
DOCTOR
Prescribing Physician Name
Address
City
State
Zip
Phone #
NPI #
Placement Facility
Alternative Physician Contact
Alternative Phone #
INSURANCE
Primary Insurance
Policy/ID #
Group #
Phone #
Secondary Insurance
Policy/ID #
Group #
Phone #
FREQEUNCY OF USE Please indicate the prescribed frequency of use and the quantity to be dispensed.
Has this patient ever ordered these supplies?

YesNo
Single Drain

Once Per Day (90 ASEPT Drainage Kits in 90 days)Every Other Day (50 ASEPT Drainage Kits in 90 days)Other
Bilateral Drain

Once Per Day (180 ASEPT Drainage Kits in 90 Days)Every Other Day (90 ASEPT Drainage Kits in 90 Days)Other
Please Note: Each case includes 10 ASEPT Drainage Kits. Each Drainage Kit contains vacuum bottles with drainage line, foam pad with slice for catheter placement, clear adhesive dressing, alcohol wipes (3), 4" x 4 " gauze pads (6), gloves (2x) and emergency slide clamp.
DIAGNOSIS PRIMARY - location of fluid accumulation (Required)
Please check appropriate diagnosis:

J91.8 Unspecified Pleural EffusionJ91.0 Malignant Pleural EffusionR18.8 Other AscitesJ90 Pleural EffusionR18.0 Malignant AscitesOther
SECONDARY - Condition Causing Drainage Treatment (Required)

C34.90 Lung CancerI50.9 Heart FailureC50.919 Female Breast CancerC56.9 Ovarian Cancer50.929 Male Breast CancerOther
I certify that I am the physician/practitioner identified on this form. I have reviewed the Physician’s Written Order. Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge. I certify I am qualified, under CMS guidelines, to sign and prescribe medical equipment and supplies. I certify that the patient/caregiver is capable and has successfully completed training or will be trained on the proper use of the products prescribed on this Written Order. The patient’s record contains supporting documentation that substitutes the utilization and medical necessity of the products listed and physician notes and other supporting documentation will be provided to cCormick upon request. I understand any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient’s medical record.
Signature

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Date

MonthDayYear
Date
NPI #
Printed Name
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E-Mail or Phone #

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This prescription or the information contained herein may be shared with or reported to PFM Medical, Inc. the product manufacturer, for quality purposes to ensure that the necessary resources are available to service patients using the ASEPT Catheter Systems product line. Such information is furnished in compliance with HIPAA to allow for the best treatment of the patient.
LS-00464-01-AG
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Pleural & Peritoneal Drainage Supplies

Physician's Written Order

QUESTIONS? Contact A Patient Representative at McCormick Medical

All field are required to process an order.

PATIENT

DOCTOR

INSURANCE

FREQEUNCY OF USE Please indicate the prescribed frequency of use and the quantity to be dispensed.

DIAGNOSIS PRIMARY - location of fluid accumulation (Required)

LS-00464-01-AG