E-FORME-FORMPRESCRIPTION FORM LETTER OF MEDICAL NECESSITY PROVIDER INFO: PATIENT INFO: You need only complete the information in this section that has not been provided on previously submitted forms. PATIENT NAME: * CHECK ONE:* MaleFemale STREET ADDRESS:* CITY, STATE, ZIP:* MOBILE PHONE:* CHECK ONE:* Major MedWorkers CompNo-FaultAuto Date of Injury/Accident (if applicable): Date Of Birth: INSURANCE COMPANY/ID #: ITEM(S) PRESCRIBED:* L0648 Aspen Horizon 631 LSO - Designed to provide trunk stability to fatigued muscles. Provides a therapeutic level of compression for patients recovering from surgery or injury. Anterior panels at each end of the brace overlap to provide added midline supportE0730 TENS Unit (Includes Supplies A4556 or A4595, and A4557) - Provides pain relief by transmitting electrical impulses through lead wires and surface electrodes to underlying nervesE0849 Theratrac Cervical Traction Unit - Offers up to 30 lbs of adjustable pneumatic pressureL0648 Theratrac Lumbar brace with Pneumatic Traction - Utilizes pneumatic bladder technology to administer a moderate lumbar decompression stretch, to gently contour the innate spinal path and unload the weight on the lower lumbarL0457 Aspen Horizon 456 TLSO - Designed to provide motion restriction, creating a dynamic environment for healing within the thoracolumbar and lumbar spineL0457 Aspen Active P-TLSO - This device is designed to actively influence posture by providing gentle support while activating and strengthening the necessary muscles that promote proper spinal alignmentL1833 Comfortland Hinged Knee Brace - An adjustable ROM hinge helps to stabilize the knee and promote proper alignmentE0731 Conductive Garment for TENSOther OTHER: Select Neck Size:* 14-16"17-18"19-20" Select Waist Size:* 27-37"37-47" PERIOD OF MEDICAL NECESSITY/ESTIMATED LENGTH OF NEED:* 6 Months9 Months12 Months Area(s) To Be Treated* Lumbar SpineThoracic SpineCervicalOther (Indicate): ICD-10 DIAGNOSIS CODES: ENTER PRIMARY DIAGNOSIS CODE:* Check or enter Secondary Diagnosis Codes below: LUMBAR CODES: M99.02M99.03M54.16M54.14M99.13Other OTHER: CERVICAL DIAGNOSIS CODES: M99.01M54.2M54.12M50.30Other OTHER: KNEE PAIN CODES: M25.369M25.469M25.669M25.561M25.562Other OTHER: OTHER ICD-10 CODES (IF APPLICABLE): I PRESCRIBE THIS EQUIPMENT BECAUSE (SYMPTOMS/OBJECTIVE FINDINGS):* FOR SPINE BRACING PLEASE CHECK THE APPLICABLE OPTION(S): To facilitate healing following a surgical procedure on the spine or related soft tissueTo facilitate healing following an injury to the spine or related soft tissueTo reduce pain by restricting mobility of the trunkTo otherwise support weak spinal muscles and/or a deformed spine TREATMENT GOALS:* Relieve Patient’s ConditionManage Chronic PainIncrease Range of MotionReduce Muscle SpasmAchieve StabilizationReduce Reliance on Pain MedicationsDisc Hydration PREVIOUS TREATMENTS:* Date of Initial Visit: Date Last Seen: I certify that the above prescribed equipment, provided by SMG Mediquip, LLC, is both reasonable and medically necessary, unless otherwise noted. PHYSICIAN NAME:* PHONE:* PHYSICIAN SIGNATURE:* DATE:* Note: Please click on the print form button in order to print a copy before submitting it to us electronically.
