Therapeutic phlebotomy order form 2026

1. Click ‘Get Form’ to open the therapeutic phlebotomy order form in the editor.
2. Begin by entering the date and time at the top of the form. This is essential for record-keeping.
3. In the first section, specify the volume of blood to be removed (in mL) and set a schedule for repeat phlebotomy based on hemoglobin levels.
4. Clearly state the goal of therapeutic phlebotomy in the designated field to ensure clarity in treatment objectives.
5. Indicate whether fluid replacement is necessary. If so, note that Normal saline 500 mL IV should be administered once.
6. List any required lab work pre-phlebotomy, including a complete blood count (CBC) and other tests as needed.
7. Document the date of the last History and Physical examination, ensuring compliance with requirements.
8. Select a diagnosis from the provided options and certify that these codes support medical necessity by checking the appropriate box.
9. Finally, ensure all signatures are completed by both providers before submission.

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