PRESCRIPTION FORM/LETTER OF MEDICAL NECESSITY
Provide patient details and equipment needs for medical treatment.
SMG MEDIQUIP, LLC
P.O. BOX 736, BETHPAGE, NY 11714
PHONE: 516-586-4934 / FAX: 800-717-2573
PATIENT INFO
Complete only the information in this section that has not been provided on previously submitted forms.
Patient Name
*
First Name
Last Name
Gender
*
Male
Female
Check One
*
Major Med
Workers Comp
No Fault
Auto
Street Address
City, State, Zip
Date of Injury/Accident (if applicable)
-
Month
-
Day
Year
Date
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company/ID#
Date of Birth
*
-
Month
-
Day
Year
Date
ITEM(S) PRESCRIBED
Select all items prescribed (descriptions included):
*
L0648 Aspen Horizon 631 LSO — Trunk stability/compression brace
E0730 TENS Unit (Includes supplies A4556/4595 and A4557) — Pain relief via electrical impulses
E0849 Theratrac Cervical Traction Unit — Cervical traction device
L0648 Theratrac Lumbar brace with Pneumatic Traction — Lumbar support with pneumatic traction
L0457 Aspen Horizon 456 TLSO — Motion restriction brace
L0457 Aspen Active P-TLSO — Posture support brace
L1833 Comfortland Hinged Knee Brace — ROM hinge knee brace
E0731 Conductive Garment for TENS
Other
If E0849 Theratrac Cervical Traction Unit selected, circle size:
*
14-16"
17-18"
19-20"
If L0648 Theratrac Lumbar brace with Pneumatic Traction selected, circle waist size:
*
27-37"
37-47"
If E0731 Conductive Garment for TENS selected, indicate treatment area:
*
If E0731 Conductive Garment for TENS selected, OTHER:
*
PERIOD OF MEDICAL NECESSITY / ESTIMATED LENGTH OF NEED
Select the estimated length of need:
*
6 Months
9 Months
12 Months
AREA(S) TO BE TREATED
Select all areas to be treated:
*
Lumbar Spine
Thoracic Spine
Cervical
Other (specify below)
If 'Other', please specify:
ICD-10 DIAGNOSIS CODES
Primary Diagnosis Code (Required)
*
Lumbar Codes
M99.02
M99.03
M54.16
M54.14
M99.13
Other (specify below)
If 'Other' for Lumbar Codes, please specify:
Cervical Codes
M99.01
M54.2
M54.12
M50.30
Other (specify below)
If 'Other' for Cervical Codes, please specify:
Knee Pain Codes (Check or enter Secondary Diagnosis below)
M25.369
M25.469
M25.669
M25.561
M25.562
Other (specify below)
If 'Other' for Knee Pain Codes, please specify:
Other ICD-10 Codes (if applicable):
I PRESCRIBE THIS EQUIPMENT BECAUSE (Symptoms/Objective Findings):
*
FOR SPINE BRACING — CHECK THE APPLICABLE OPTION(S):
To facilitate healing following a surgical procedure on the spine or related soft tissue
To facilitate healing following an injury to the spine or related soft tissue
To reduce pain by restricting mobility of the trunk
To otherwise support weak spinal muscles and/or a deformed spine
TREATMENT GOALS:
*
Relieve Patient's Condition
Increase Range of Motion
Manage Chronic Pain
Achieve Stabilization
Reduce Muscle Spasm
Reduce Reliance on Pain Medications
Disc Hydration
Previous Treatments
*
Date of Initial Visit
-
Month
-
Day
Year
Date
Date Last Seen
*
-
Month
-
Day
Year
Date
Certification: I certify that the above prescribed equipment is medically necessary for the patient indicated above.
Physician Name
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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