Follow the steps to complete the Detailed Written Order form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the order date in the designated field to indicate when the order was created.
3. Select the order type by checking the appropriate box: Initial, Revised, or Recertification.
4. Indicate the length of need (LON) by entering a number between 1 and 99 months, where 99 signifies lifetime requirement.
5. Fill in the patient's date of birth (DOB) in the provided space to identify the individual receiving the order.
6. Provide the physician's name and the National Provider Identifier (NPI) in their respective fields.
7. Include the physician's phone number and fax number, ensuring accurate contact information.
8. List the diagnoses and corresponding ICD-10 codes in the areas marked, using separate fields for each diagnosis.
9. For equipment and accessories, fill out the required fields by entering the HCPCS code, item description, and the quantity ordered for each item needed.
10. Ensure the physician reviews the form, then sign and date it where indicated, as signatures and date stamps are required.
11. After completing the form, you can save your changes, download it for printing, or share it as needed.

Complete your DETAILED WRITTEN ORDER online for Bluegrass Oxygen today to ensure timely processing.