DYNASPLINT® SYSTEM(S) PRESCRIBED Physician’s Name [Please Print] Phone Number NPI Number Street Address City State Zip Code Physician’s Signature Primary Diagnosis Code Tertiary Diagnosis Code Length of Time Needed: Resting Hand/Wrist Orthosis MPO 2000® Active Ankle-Foot Orthosis NeuroFlex ™ Restorative ™ Knee Orthosis NeuroFlex ™ Restorative ™ Elbow Orthosis RestAir ™ Hip Orthosis Stretch Beyond Your Expectations. ® 3 Months 6 Months 12 Months Lifetime Other: DIAGNOSIS ATTACHMENTS OR ACCESSORY ITEM(S) PATIENT INFORMATION CERTIFICATE OF MEDICAL NECESSITY – NEUROLOGICAL ACCESSORY ITEMS Anti-Spasticity Ball Hand/Wrist Attachment Mitt Hand/Wrist Attachment Padded Palmar Hand/Wrist Attachment Hand Pan C-Cup Hand/Wrist Attachment Universal Flat Hand/Wrist Attachment PHONE e-FAX PHYSICIAN INFORMATION AND SIGNATURE FAX TO NO SUBSTITUTIONS ALLOWED – In my opinion, in accordance with accepted medical practice standards, the above named patient requires the exact Dynasplint ® System(s) as dispensed by Dynasplint Systems, Inc., for the diagnosis indicated. This form is needed to bill the patient’s insurance. Please complete and return. N Patient currently in a therapy program? Yes Name of Therapy Clinic: L L L L L R R R R L L L L L R R R R R L NEUROLOGICAL DIVISION SIGN SALES CONSULTANT Fax Number Date Date of Onset/Surgery/Injury Quaternary Diagnosis Code Secondary Diagnosis Code DATE WRIST EXTENSION HAND/WRIST ATTACHMENTS No Date of Onset/Surgery/Injury Date of Onset/Surgery/Injury Date of Onset/Surgery/Injury Kentucky Kollar L R DS1971 Inversion/Eversion Control System R Other: Other: R Replacement Soft Interface Material for: Shoulder Elbow Forearm Wrist Finger Hand(MCP) Knee Ankle First Name Start Date of Order (MM/DD/YY) Date of Birth Last Name Corporate Headquarters: 770 Ritchie Highway, Suite W-21 Severna Park, MD 21146-3923 Phone: 800.638.6771 / 410.544.9530 FAX TO: www.dynasplint.com Shoulder Right Elbow Extension Forearm n o i t a n i p u S Wrist Extension Hand (MCP) Flexion Finger Extension Knee Extension Ankle External Rotation Extension Pronation Plantar Flexion Flexion Internal Rotation Abduction Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left 5 1 2 3 4 5 1 2 3 4 Flexion Flexion Flexion Dorsiflexion Flexion Toe Extension Right Left 5 1 2 3 4 5 1 2 3 4 Flexion Toe
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
DYN
ASP
LIN
T® S
YSTE
M(S
)PR
ESCR
IBED
Physician’s Name [Please Print] Phone Number
NPI Number
Street Address City State Zip Code
Physician’s Signature
Primary Diagnosis Code
Tertiary Diagnosis Code
Length of Time Needed:
Resting Hand/Wrist Orthosis
MPO 2000® Active Ankle-Foot OrthosisNeuroFlex™ Restorative™ Knee Orthosis
NeuroFlex™ Restorative™ Elbow Orthosis
RestAir™ Hip Orthosis
Stretch Beyond Your Expectations.®
3 Months 6 Months 12 Months Lifetime Other:
DIA
GN
OSI
SAT
TACH
MEN
TS O
RA
CCES
SORY
ITEM
(S)
PATI
ENT
INFO
RMAT
ION
CERTIFICATE OF MEDICAL NECESSITY – NEUROLOGICAL
ACCESSORY ITEMS
Anti-Spasticity Ball Hand/Wrist AttachmentMitt Hand/Wrist AttachmentPadded Palmar Hand/Wrist AttachmentHand Pan C-Cup Hand/Wrist AttachmentUniversal Flat Hand/Wrist Attachment
PHONE e-FAX
PHYS
ICIA
N IN
FORM
ATIO
N
A
ND
SIG
NAT
URE
FAX
TO
NO SUBSTITUTIONS ALLOWED – In my opinion, in accordance with accepted medical practice standards, the above named patient requires the exact Dynasplint® System(s) as dispensed by Dynasplint Systems, Inc., for the diagnosis indicated.
This form is needed to bill the patient’s insurance. Please complete and return.
N
Patient currently in a therapy program? Yes Name of Therapy Clinic:
L
LL
L
L
R
RR
R
LLLLL
RRRRR
L
NEUROLOGICAL DIVISION
SIGN
SALES CONSULTANT
Fax Number
Date
Date of Onset/Surgery/Injury
Quaternary Diagnosis Code
Secondary Diagnosis Code
DATE
WRIST EXTENSION HAND/WRIST ATTACHMENTS
No
Date of Onset/Surgery/Injury
Date of Onset/Surgery/Injury Date of Onset/Surgery/Injury
Kentucky Kollar
L
R DS1971 Inversion/Eversion Control System R Other:
Other:
R Replacement Soft Interface Material for: Shoulder Elbow Forearm Wrist Finger Hand(MCP) Knee Ankle
First Name
Start Date of Order (MM/DD/YY) Date of Birth
Last Name
Corporate Headquarters: 770 Ritchie Highway, Suite W-21 Severna Park, MD 21146-3923
Phone: 800.638.6771 / 410.544.9530
FAX TO:www.dynasplint.com
Shoulder Right
Elbow Extension
Forearm noitanipuS
Wrist Extension
Hand (MCP) Flexion
Finger Extension
Knee Extension
Ankle
External Rotation
Extension
Pronation
Plantar Flexion
Flexion
Internal Rotation Abduction Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
51 2 3 4 51 2 3 4
Flexion
Flexion
Flexion
Dorsiflexion
Flexion
Toe ExtensionRight Left
51 2 3 4 51 2 3 4Flexion
Toe
Related Documents
