If your patient qualifies for therapy, please fax the following to our office at (262)521-2249:
- Phone number
- Insurance information
5 Element Order Prescription including:
- Patient's name
- Description of the item
- Physician signature
- Physician's NPI
**Click here to download a Detailed Written Order Form**
Physician signed clinical notes from the past 30 days supporting medical necessity and discussing symptoms/prognosis (Shortness of Breath, chronic respiratory indications, hypoxia-related symptoms, etc.) Diagnosis alone is not sufficient. A chart note’s primary purpose is to demonstrate the clinical necessity and show why the patient requires therapy.
A valid note should include:
- Pulmonary diagnosis
- Medication and delivery modality
- Medication list
- Nebulizer is needed to deliver a respiratory medication
- Duration of the patient's medical condition
- Clinical course (worsening or improvement)
- Nature and extent of functional limitations
- Length of need
- Other therapeutic interventions and results (e.g. past experiences with related items)
- Why does the patient require the item?
- Physical exam findings
- Signs and symptoms that indicate the need for the item
- Refill quantity (e.g. Refills: portable monthly x 12 mo./stationary monthly x 12 mo.)
- Practitioner's signature
For further information on Medicare’s coverage guidelines, click here for their LCD.
If you have questions about the referral process at any time, please contact our office for assistance.