If your patient qualifies for therapy, please fax the following to our office at (262)521-2249:

Patient Demographics

  • Name
  • DOB
  • Phone number
  • Address
  • Insurance information

5 Element Order Prescription including:

  • Patient's name
  • Description of the item
  • Physician signature
  • Physician's NPI
  • Date

**Click here to download a Detailed Written Order Form**

Chart notes

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)
  • Prognosis
  • 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.