Get Hill Rom Vest Order Form

Completing the Hill Rom Vest Order Form online is a straightforward process that enables healthcare providers to efficiently order the Vest® Airway Clearance System for patients. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the Hill Rom Vest Order Form and open it in the editing interface.
2. Enter the patient's birth date and full name in the designated fields, ensuring to fill in all required sections.
3. Select the gender of the patient and provide the complete address, including street, city, state, and zip code.
4. Input the primary and secondary insurance information along with the associated ID numbers.
5. Fill in the patient contact name, primary language, and phone numbers (home, cell, and alternate).
6. Record the chest measurement as required, and choose the garment style from the provided options (full vest, wrap vest, or chest vest).
7. Indicate whether the patient is currently in the hospital and provide the discharge date if applicable.
8. Completing the healthcare provider section includes marking whether alternative airway clearance techniques have been attempted and failed, and indicating methods that apply to the patient.
9. Check all applicable reasons and relevant medical history related to the patient’s respiratory condition.
10. If applicable, confirm whether a CT scan has been done for bronchiectasis diagnosis by checking yes or no, and attach any required reports.
11. Enter the prescriber's signature, printed name, primary diagnosis information, and associated codes.
12. If a 30-day trial is desired for the patient, make sure to check the appropriate box.
13. Fill in the facility contact person information and include the following physician or primary care provider's details.
14. After filling out all sections, save the completed form, then download, print, or share it as needed.

Start now by completing the Hill Rom Vest Order Form online to ensure timely treatment for your patient.