Get Demographic Face Sheet

Completing the Demographic Face Sheet online can help ensure that the necessary patient information is accurately recorded and submitted for processing. This guide will walk you through the key sections of the form and provide clear instructions to assist you in filling it out effectively.

Follow the steps to complete your Demographic Face Sheet online:

1. Press the ‘Get Form’ button to obtain the Demographic Face Sheet and open it in your preferred online editor.
2. In the 'Patient Information' section, fill in the name fields, including last name, first name, and middle initial. Provide your full street address, city, state, and zip code.
3. Next, enter your contact information by providing your evening phone, daytime phone, and cellular number. Include your date of birth and indicate whether an interpreter is needed.
4. For diagnosis information, input the primary and secondary ICD-10 diagnosis codes along with their respective descriptions. Ensure these details are thorough and accurate.
5. Complete the 'Airway Clearance Therapy Tried and Failed' section by checking all applicable therapies. Document any reasons why the therapy may not be suitable for the patient.
6. In the 'Medical History' section, indicate any relevant medical procedures or conditions from the past year. Attach any necessary medical records as indicated.
7. For the prescription information, fill out the details concerning the prescribed SmartVest® Airway Clearance System, including the quantity and length of need.
8. Sign the physician certification area to validate the information provided. Make sure to print the physician’s name, NPI, and contact details.
9. Review all entered information for accuracy. Save changes within the online editor, and prepare to download or print the completed form.
10. Finally, submit the completed Demographic Face Sheet and associated documents via fax to the designated number, ensuring all parts are sent for processing.

Start filling out your Demographic Face Sheet online today to ensure timely and accurate processing of your healthcare documents.