Get Statement Of Ordering Physician Pulmodose Nebulizer Medications - Pd 165

This guide provides clear and supportive instructions for filling out the Statement Of Ordering Physician PulmoDose Nebulizer Medications - PD 165 online. Follow the steps outlined below to complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Press the 'Get Form' button to access the PD 165 online. This allows you to obtain the electronic version of the form that you can fill out directly.
2. Begin by entering the patient's information in the designated fields. Include the patient's full name, date, address, phone number, social security number, date of birth, height, weight, and any relevant diagnosis such as chronic bronchitis or COPD.
3. Fill in the drug allergies section to note any medications that the patient is allergic to. This is crucial for safe medication administration.
4. Provide insurance information by specifying the primary and secondary insurance carriers, along with their respective group numbers, policy numbers, and contact phone numbers.
5. In the respiratory equipment section, indicate the necessary oxygen details including liters per minute (LPM), hours per day, and whether the patient requires continuous or nocturnal oxygen.
6. Complete the nebulizer medications section by selecting the appropriate medications to be administered via nebulizer/compressor. Indicate the prescribed doses and frequency (e.g., QID or BID) for each medication.
7. Specify the length of need for the nebulizer medications, choosing either 12 months or another specified duration, and include instructions for the dispense of reusable nebulizer kits.
8. Fill in the physician's information, including their name, address, signature, NPI, state licensing number, DEA number, and contact information.
9. Review all entered information for completeness and accuracy before finalizing your submission.
10. Once all sections are filled out correctly, save changes, and use options for downloading, printing, or sharing the completed form as needed.

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