
Get Care Fusion Pleurx Order Form 2020-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Care Fusion Pleurx Order Form online
Filling out the Care Fusion Pleurx Order Form is a straightforward process that requires attention to detail. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.
Follow the steps to effectively complete the Pleurx Order Form.
- Click ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
- Begin with Section A, filling in the required patient information accurately. Provide the patient's name, phone number, date of birth, sex, address, city, state, ZIP code, physician's name, and phone number.
- Proceed to Section B, which involves entering the primary and secondary diagnosis. Ensure you check the appropriate boxes for each diagnosis and include any additional necessary details.
- Indicate the duration of need in months and the required start date using the options provided. Make sure to respond to the questions regarding drainage needs by marking 'Y' for yes, 'N' for no, or 'D' for does not apply.
- Fill in the placement date and discharge date as specified. Next, specify the prescribed frequency of use and the number of PleurX Drainage Kits to be dispensed.
- In Section C, the physician will need to certify their credentials and ensure that all the information provided is accurate. They must sign the form and include their printed name, date, and NPI number.
- Provide patient insurance information to ensure timely shipment of supplies. Fill out details such as primary and secondary insurance, policyholder information, and hospital contact information if applicable.
- Once all sections are complete, review the form for accuracy. You may then save the changes, download, print, or share the form as needed.
Complete the Care Fusion Pleurx Order Form online today for a seamless process.
Disposing of PleurX drains requires careful handling to prevent contamination. First, seal the used drains in a plastic bag and follow your local hazardous waste disposal procedures. Consulting with your healthcare provider for specific disposal guidelines is also recommended. To obtain replacement drains conveniently, remember to check out the Care Fusion Pleurx Order Form for a seamless ordering experience.
Fill Care Fusion Pleurx Order Form
All fields are required to process an order. Primary – Location of Fluid Accumulation (Required). All fields are required to process and order. Please fax completed forms to . Edit, sign, and share pleurx catheter order form online. CAREFUSION. PleurX™ catheter system. Request Information. The document provides a comprehensive form for collecting patient insurance and medical information related to the PleurX® Drainage Kits. For bulk orders, clinical support, or further assistance, contact CIA Medical customer service at or use the contact form on this page.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.