Get Medical Service Company Order Form

Filling out the Medical Service Company Order Form online is a straightforward process that ensures you provide all necessary information for medical services. This guide will walk you through each section of the form, making it easy to complete your request accurately.

Follow the steps to fill out the Medical Service Company Order Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by entering the patient's name in the designated field, followed by the date prescribed, ensuring you use the correct format for the date.
3. Fill in the patient's address, city, zip code, and insurance information thoroughly to avoid any processing delays.
4. Provide the patient's home or cell phone number, along with their length of need, height, weight, date of birth, and gender. Make sure all values are precise.
5. Check off the applicable diagnosis codes for the patient's condition, using the provided list to ensure you select the correct options.
6. Specify the oxygen requirements by detailing liters per minute (LPM) and the duration of use. Be sure to indicate whether the patient needs a conserving device.
7. Include any pulse oximetry services required, noting if a comprehensive oximetry is requested.
8. For nebulizer and respiratory medications, select the frequency of usage and attach a copy of the prescription if applicable.
9. List the details for CPAP/Bi-level therapy, including cm H2O specifications and other accessories needed, ensuring to mention if a sleep study is included.
10. Provide details for enteral or tube feeding, including the formula and flushing instructions as necessary.
11. Complete the section for diabetic supplies by checking the relevant options and specifying the testing frequency per day.
12. Fill out the durable medical equipment (DME) section with the necessary ambulatory devices, beds, support surfaces, and daily living aids required by the patient.
13. Obtain the physician's signature along with the date, printed name, phone number, fax number, address, and their National Provider Identifier (NPI).
14. Lastly, enter your name as the person filling out the form and indicate if a phone call to verify receipt of the fax is needed.
15. Once all sections are completed, review for accuracy, save your changes, and then choose to download, print, or share the form as needed.

Start filling out your Medical Service Company Order Form online today for efficient order processing.