Get Fitzsimmons Order Form

Filling out the Fitzsimmons Order Form online can seem overwhelming, but this guide will walk you through each step. By following these clear instructions, you can ensure that your form is completed accurately and efficiently.

Follow the steps to successfully complete the order form.

1. Click 'Get Form' button to access the order form and open it.
2. Begin by entering the patient information. Fill in the patient's name, phone number, address, date of birth, and gender. Ensure all fields are completely and accurately filled out.
3. Provide the primary and secondary insurance information. Indicate the type of insurance and enter the corresponding policy or group numbers.
4. Detail any chronic respiratory conditions the patient may have by checking the appropriate boxes, including asthma, COPD, or other specified conditions.
5. In the oxygen therapy section, input the liters per minute (LPM) needed and specify the duration of need. Indicate if the oxygen is to be used continuously or nocturnally. Fill in the qualifying test results and testing facility information.
6. For aerosol therapy, select the medications required and specify the dosage and frequency of administration. Fill in the start date for the medication and any refill details.
7. Complete the sleep therapy section by indicating if a CPAP or BiPAP is required, along with any heated humidifiers. Specify the length of need and attach a sleep study if required.
8. Select any durable medical equipment needed and indicate the length of need. This includes items such as hospital beds and wheelchairs.
9. Provide physician information including name, contact details, and signature. Ensure that the NPI number is included for processing.
10. Review all entries for completeness and accuracy. Once satisfied with the information provided, you can choose to save changes, download, print, or share the completed order form.

Begin completing your Fitzsimmons Order Form online today for efficient submission.