Follow the steps to complete the form online.

1. Click ‘Get Form’ button to retrieve the form and open it for editing.
2. Begin by entering the patient’s full name and date of birth in the designated fields. Ensure that the information is correct to avoid any delays in care.
3. Fill in the patient's address, phone number, city, state, and ZIP code. Accurate contact information is essential for effective communication about the care process.
4. Provide information about the health plan and the member ID number. Also, indicate the authorization number if available.
5. If the patient is under a Home Health Agency, fill in the agency name and their phone number. This information assists in coordinating care.
6. Document the primary diagnosis and wound locations by entering the appropriate ICD-10 code along with a description.
7. Select the number of refills needed for each wound and indicate the duration for which the orders are placed (30 days or 14 days). Fill in the start date.
8. Use checkmarks to select the primary and secondary dressings for each wound. Note that each dressing type can only be selected for one wound unless supported by additional documentation.
9. Complete the additional medical information section, including details for each wound such as location, length, width, and depth. Accurate measurements are vital for selecting appropriate dressings.
10. Indicate the frequency of dressing changes and, if applicable, provide additional information on separate paper for any extra wounds.
11. Fill in the doctor’s name, NPI number, and their phone number. Ensure that the doctor’s signature is included along with the date to validate the order.
12. Review all entered information for accuracy and completeness. Once everything is correct, save changes, download, print, or share the completed form as necessary.

Complete your documents online today to ensure prompt and effective wound care solutions.