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Get Byram Healthcare Physician's Order - TheraGauze

I authorize the benefits payable to Byram Healthcare on assigned claims. I authorize Byram Healthcare to submit claims to Medicare and/or any other Medical Insurance carrier. I agree to assume responsibility for any balances for supplies furnished to me by Byram Healthcare not approved by my insurance policy. I authorize the release to Byram Healthcare any medical information including the diagnosis that may be necessary for insurance payment. Physician s Order - TheraGauze Referral Customer Service 800 334-0235 x33960 Fax Acc t Name Patient Re-order Name Order Date Address Apt St Male D. O. B. Female Zip Medicare Tel Medicaid SSN Policy Gp Other Ins Ins Tel of Ordered By F City Diabetes Is the patient being seen by a home health agency Yes Physician 800 521-6291 Acc t Tel Face Sheet Attached L Account Fax No 164982 Fax Confirmation NPI Signature x Date Duration of Need Wound Dimensions cm s Location Type or ICD. 9 code Length Width mths Drainage Depth Dry Lt Mod Thickness Hvy Part Full Debridement or Surgery Date Dressings Days Supply Call your local Byram Account Manager at 1 877 902 8726 for information on TheraGauze Starter Kits Medicare Guidelines Full Thickness Dry to Light Drainage Wounds Up-to 30/month TheraGauze 2 x 2 Primary Dressing SS9492268294 QD Conforming Bandage Sterile Q2D Q7D Other Other Secondary Secondary Dressing one per wound Q3D Size Tape Paper Cloth Other Supplies Patient Authorization of Release of Information and Assignment of Benefits My signature on the line below authorizes any of the following. I certify that the information given by me in applying for payment under Medicare Title XVIII of the Social Security Act and/or any other Medical Insurance is correct. This includes but is not limited to deductibles coinsurance and non covered items. I authorize that photo copies shall be valid as originals. Physician s Order - TheraGauze Referral Customer Service 800 334-0235 x33960 Fax Acc t Name Patient Re-order Name Order Date Address Apt St Male D. O. B. Female Zip Medicare Tel Medicaid SSN Policy Gp Other Ins Ins Tel of Ordered By F City Diabetes Is the patient being seen by a home health agency Yes Physician 800 521-6291 Acc t Tel Face Sheet Attached L Account Fax No 164982 Fax Confirmation NPI Signature x Date Duration of Need Wound Dimensions cm s Location Type or ICD. O. B. Female Zip Medicare Tel Medicaid SSN Policy Gp Other Ins Ins Tel of Ordered By F City Diabetes Is the patient being seen by a home health agency Yes Physician 800 521-6291 Acc t Tel Face Sheet Attached L Account Fax No 164982 Fax Confirmation NPI Signature x Date Duration of Need Wound Dimensions cm s Location Type or ICD. 9 code Length Width mths Drainage Depth Dry Lt Mod Thickness Hvy Part Full Debridement or Surgery Date Dressings Days Supply Call your local Byram Account Manager at 1 877 902 8726 for information on TheraGauze Starter Kits Medicare Guidelines Full Thickness Dry to Light Drainage Wounds Up-to 30/month TheraGauze 2 x 2 Primary Dressing SS9492268294 QD Conforming Bandage Sterile Q2D Q7D Other Other Secondary Secondary Dressing one per wound Q3D Size Tape Paper Cloth Other Supplies Patient Authorization of Release of Information and Assignment of Benefits My signature on the line below authorizes any of the following. .

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