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Blood assurance therapeutic phlebotomy form

How to find request for therpeutic phlebotomy forms for blood assurance 2025

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The document is a request form for therapeutic phlebotomy, detailing patient information, diagnosis, and requirements for blood donation. It specifies the conditions under which phlebotomy can be performed, including hemoglobin levels and frequency of donations. The form must be completed by both the attending physician and the donor, ensuring compliance with FDA regulations.

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How to order a therapeutic phlebotomy?

Zubair8 has described various criteria for initiating therapeutic phlebotomy, which include ferritin levels of 200 ng/mL for ages of 500 ng/mL for women who are not pregnant but are of childbearing age, and ferritin levels of 300 ng/mL for men who are 18 years old.

What are the criteria for therapeutic phlebotomy?

Therapeutic Phlebotomy (CPT Code 99195) Therapeutic phlebotomy (CPT 99195) may only be considered medically necessary when billed with the indications/diagnosis codes listed below. Claims billed with a diagnosis code not listed here will be denied as not medically necessary.

How to get a therapeutic phlebotomy?

If you would like to receive this free service, please ask your physicians office to submit an electronic physicians order form. All therapeutic phlebotomy orders must be submitted electronically.

When should I order a therapeutic phlebotomy?

Therapeutic phlebotomy may be indicated for hemochromatosis, polycythemia vera, porphyria cutanea tarda, and polycythemia secondary to arterio-venous fistulae, cyanotic congenital heart disease or cor pulmonale.

Is therapeutic phlebotomy covered by insurance?

Many insurers cover therapeutic phlebotomies. Please contact your insurance company for more information on their reimbursement procedures.

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