Get Catheter Order Form

Completing the Catheter Order Form online is a straightforward process that ensures accurate documentation for medical supplies. This guide will provide you with step-by-step instructions to help you fill out the form effectively and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the provider information, including the provider’s name, phone number, fax, and provider number.
3. Enter the patient’s details, including their phone number, date of birth, initial date, revised date, recertification, and length of need in months.
4. Complete the physician section by providing the physician's UPIN, phone number, NPI, and fax number.
5. Document the diagnosis by entering the ICD-9 code associated with the patient's condition.
6. In the equipment/services section, specify the quantities and procedure codes for the requested items, including a description of each.
7. Indicate any additional medical information by checking the relevant diagnosis options, confirming whether the patient has had urinary tract infections, and noting the number of UTIs within the past twelve months.
8. Attach any necessary documentation such as patient demographics, progress notes, or urine cultures.
9. Select urological supplies requested by marking the appropriate boxes, and specify any additional items as needed.
10. Indicate the catheter size and the number of times the patient will be catheterized per day.
11. Complete the length of the prescription by noting the number of months for which the supplies are required.
12. Ensure the physician signs and dates the form for validation.
13. Once all sections are complete, save your changes, and download or print the form as needed for sharing or submission.

Start completing your Catheter Order Form online today!