Pain Rehab Products, Inc in Saint Louis, Missouri - Address 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for medical records.
3. Fill in the patient's address completely to avoid any issues with communication or delivery.
4. Input the diagnosis codes ICD-10 for both primary and secondary conditions. This is essential for insurance processing.
5. Select the appropriate orthosis options by checking the boxes next to LSO or TLSO types that apply to your patient’s needs.
6. Indicate how long the patient has had their condition and specify the length of need for equipment using months or years.
7. Check all applicable conditions that justify the need for prescribed equipment, ensuring all relevant details are documented.
8. The physician must sign and date the form, ensuring that a printed name and NPI number are also included. Remember, stamped signatures are not acceptable.
9. Finally, fax the completed form along with required medical records to ensure compliance with Medicare requirements.

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