Ambulatory Equipment Wheelchair Assisted Daily Living Equipment Accessories: Accessories Other: Walker: Standard: Hospital Bed Patient Lift Bed: With Arms With Lock Without Lock Without Arms With Back Without Back Toilet Seat: Bath Seat: Standard Padded Transfer Bench: Grab Bar: Commode: Drop Arm Heavy Duty 12” Std 16” 18” 24” 32” With Wheels Without Wheels 4-Wheeled with Seat Hemi Walker Cane: Quad Cane Straight Cane Crutches: Standard Forearm Platform Attachment: Left Right Both 16” Full-Electric Lift: Standard Heavy Duty Sling: Standard With Without Commode Opening Semi-Electric Innerspring Mattress Siderails: Full Half Trapeze: Floor Base Bed Mount Gel Overlay Alternating Pressure Pad Low Air Loss Mattress Foam Overlay Manual Heavy Duty 18” Other: Other: Lightweight: 16” 18” Heavy Duty >250: 20” Heavy Duty >300: 22” 24” Anti-Tippers Brake Extensions Seatbelt Arm Rests: Detachable Fixed Foot Rests: Standard Elevating Wheelchair Cushions: General Purpose Adjustable Back Gel Stump Support: Left Right Hemi: 16” 18” 20” 22” Size: Heavy Duty With Without Commode Opening Size: Transfer Board: 24” 30” PHYSICIAN’S ORDER FOR MEDICAL EQUIPMENT KEENE MEDICAL PRODUCTS, LLC. MEDICAL SALES HOME RENTAL HOME CARE IS OUR BUSINESS KEENE MEDICAL PRODUCTS “Bringing Healthcare Home Since 1975.” 5 Landing Road, Enfield, NH 03748 Phone: (855) 622-5556 Fax: (855) 722-5556 Patient Name: Date of Birth: Height: ft. Supporting Diagnosis: ICD Code: Insurance 1: Discharge Date: Weight: lbs. Primary Care Physician: Room #: Or # of Months: Length of Need: Lifetime ID: Insurance 2: ID: ICD Code: in. Place of Service: Facility Name: Home Facility MRKT - 006 REV/CF - 7/20 All order forms MUST be signed by the physician AND accompanied by: Pa�ent Demographic Sheet and Medical Documenta�on. Physician’s Signature: Physician’s Name: Physician’s Medicaid Provider #: Order & Signature Date: NPI #: (Signature Stamps Not Allowed) Walker Accessories: Basket Glide Brakes Tray Leg Extensions I, the undersigned, certify that the above prescribed equipment and/or supplies are reasonable and medically necessary as part of the treatment of this patient. The need and medical necessity for the above listed equipment and/or supplies are documented in the patient’s medical record.
Transcript
Ambulatory Equipment
Wheelchair
Assisted Daily Living Equipment
Accessories:
Accessories
Other:
Walker:
Standard:
Hospital Bed
Patient Lift
Bed:
With ArmsWith Lock Without Lock
Without ArmsWith Back Without Back
Toilet Seat:
Bath Seat:Standard PaddedTransfer Bench:
Grab Bar:Commode: Drop Arm Heavy Duty
12”Std
16” 18” 24” 32”
With Wheels Without Wheels4-Wheeled with SeatHemi Walker
Cane: Quad Cane Straight CaneCrutches: Standard Forearm
Platform Attachment: Left Right Both
16”
Full-Electric
Lift: Standard Heavy DutySling: Standard With Without Commode Opening
Semi-ElectricInnerspring Mattress
Siderails: Full HalfTrapeze: Floor Base Bed Mount
Gel Overlay
Alternating Pressure PadLow Air Loss Mattress
Foam OverlayManual Heavy Duty
18”
Other:
Other:
Lightweight: 16” 18”
Heavy Duty >250: 20”Heavy Duty >300: 22” 24”
Anti-Tippers Brake ExtensionsSeatbeltArm Rests: Detachable FixedFoot Rests: Standard Elevating
Wheelchair Cushions: General Purpose Adjustable BackGel
All order forms MUST be signed by the physician AND accompanied by: Pa�ent Demographic Sheetand Medical Documenta�on.
Physician’s Signature:
Physician’s Name:
Physician’s Medicaid Provider #:
Order & Signature Date:
NPI #:(Signature Stamps Not Allowed)
Walker Accessories: Basket Glide Brakes Tray Leg Extensions
I, the undersigned, certify that the above prescribed equipment and/or supplies are reasonable and medicallynecessary as part of the treatment of this patient. The need and medical necessity for the above listed
equipment and/or supplies are documented in the patient’s medical record.
Cane, Crutches or Walker1. Does the patient have a mobility limitation thatsignificantly impairs their ability to participate in one ormore mobility-related activities of daily living (MRADL)in the home? Relevant MRADLs are toileting, feeding,dressing, grooming and bathing.A mobility limitation is one that:a) Prevents the patient from accomplishing the MRADLentirely, or;b) Places the patient at reasonably determinedheightened risk of morbidity or mortality secondary tothe attempts to perform an MRADL, or;c) Prevents the patient from completing the MRADLwithin a reasonable time frame.
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Manual Wheelchair Bases1. Does the patient have a mobility limitation thatsigni�cantly impairs their ability to participate in oneor more mobility-related activities of daily living(MRADL) in the home? Relevant MRADLs are toileting,feeding, dressing, grooming and bathing.A mobility limitation is one that:a) Prevents the patient from accomplishing the MRADLentirely, or;b) Places the patient at reasonably determinedheightened risk of morbidity or mortality secondary tothe attempts to perform an MRADL, or;c) Prevents the patient from completing the MRADLwithin a reasonable time frame.
Wheelchair Cushion1. Does the patient have a history of or has a currentpressure ulcer area of contact with the seating surface?
Bedside Commode1. Is the patient confined to a single room?
Hospital Bed1. Does the patient have a condition which requires positioning of the body in ways not feasible with an ordinary bed?
2. Is the patient able to safely use the equipment?
3. Can the functional mobility deficit besufficiently resolved by the use of the equipment?
2. Is there an absent or impaired sensation in the areaof contact with the seating surface as a result of thepatient’s diagnosis?
3. Does the patient have the ability to carry out afunctional weight shift?
5. Does the patient have a body con�guration thatrequires additional seat width?
4. Is a commode chair with detachable arms necessaryto facilitate transferring the patient?
3. Is the patient confined to the home where there areno toilet facilities in the home?
2. Is the patient confined to one level of the homeenvironment where no toilet is available on that level?
9. If necessary, does the patient have a caregiver who isavailable, willing and able to provide assistance withthe wheelchair?
8. If the answer to question #7 is “No”, would thepatient be able to adequately self-propel in thewheelchair which has been ordered?
7. Does the patient have sufficient upper extremityfunction and other physical and mental capabilitiesneeded to safely self-propel the manual wheelchairthat is provided in the home during a typical day?
6. Has the patient expressed an unwillingness to usethe manual wheelchair that is provided in the home?
5. Will the manual wheelchair be used by the patienton a regular basis?
4. Will the use of the wheelchair significantly improvethe patient’s ability to participate in MRADLs?
3. Does the patient’s home provide access betweenrooms, maneuvering space and surfaces for use of themanual wheelchair that is provided?
2. Can the patient’s mobility limitation be sufficientlyresolved by the use of an appropriately fitted cane orwalker?
6. Does the patient require frequent changes in body position and / or has an immediate need for a change in bodyposition?
5. Does the patient require a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair orstanding position?
4. Does the patient require traction equipment which can only be attached to a hospital bed?
3. Does the patient require the head of the bed to be elevated more than 30 degrees most of the time due to congestiveheart failure, chronic pulmonary disease or problems with aspiration? Pillows or wedges must have been considered andruled out.
2. Does the patient require positioning of the body in ways not feasible with an ordinary bed to alleviate pain?
