Catheter order form 2026

1. Click ‘Get Form’ to open the catheter order form in the editor.
2. Begin by filling in the PROVIDER section with your name, phone number, fax, and provider number. This information is essential for processing the order.
3. Next, complete the PATIENT section with the patient's details including their phone number, date of birth (DOB), initial and revised dates, recertification status, and length of need in months.
4. In the PHYSICIAN section, provide your UPIN, phone number, NPI, and fax. This ensures that all medical professionals involved are properly identified.
5. Fill out the DIAGNOSIS section by checking all applicable ICD-9 codes related to the patient's condition. This helps in justifying the need for equipment/services.
6. Indicate whether the patient has had any urinary tract infections by selecting YES or NO. If yes, specify how many UTIs occurred within a twelve-month period.
7. Attach any necessary documentation such as patient demographics or urine cultures as indicated in the additional medical information section.
8. Select the urological supplies requested from the list provided and specify any additional supplies needed.
9. Finally, indicate catheter size and frequency of use per day to calculate total units required per month before signing and dating at the bottom of the form.

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