Get Statement Of Ordering Physician Group 1 Support Surfaces Statement Of Ordering Physician Group 1

Filling out the Statement Of Ordering Physician Group 1 Support Surfaces form is an essential step in ensuring patients receive the necessary support surfaces. This guide will help users navigate the form online with clarity and efficiency.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the patient's name in the designated field at the top of the form.
3. Input the Health Insurance Claim number (HIC #) in the specified area to ensure proper identification.
4. The supplier will fill in the cost information. If you are the supplier, write the supplier's charge and the Medicare fee schedule allowance in the provided fields.
5. Indicate the patient's condition by circling all applicable options from the list provided, such as immobility or presence of pressure ulcers.
6. Estimate the length of need in months by filling in the appropriate number. Note: if the need is for a lifetime, enter '99'.
7. If none of the conditions apply, attach a separate document that outlines the medical necessity for the ordered item.
8. Enter the physician's name clearly in the printed or typed section.
9. The physician must provide their signature to validate the form. Ensure this is completed.
10. Lastly, record the physician's Unique Physician Identification Number (UPIN) in the allocated space.
11. Review all information for accuracy, then save your changes, or download and print the completed form as needed.

Initiate your online process by completing the necessary documents now.