Please include the Patient Demographic Sheet with this ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth (DOB), and Phone Number in the designated fields. If applicable, include the Facility name and Fax number.
3. In the Primary Diagnosis section, select the appropriate ICD-10 code that corresponds to the patient's condition. You can choose from options like Urinary Incontinence or Neurogenic Bladder.
4. Indicate the Length of Need by selecting either 'Lifetime' or specifying another duration. Fill in any required refills as necessary.
5. Answer whether the patient has a latex allergy and if they are currently being seen by Home Health. Also, indicate if they have received any supplies within the last 30 days.
6. For Urology Supplies Needed, specify quantities and details for items such as Intermittent Catheters and Foley Catheters, including type, size, and frequency of use.
7. Complete additional notes if necessary and provide Physician Name, NPI number, Phone number, Address, and Signature along with the date at the bottom of the form.

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