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- Click ‘Get Form’ to open it in the editor.
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- Fill in the patient's address, including the zip code, followed by their primary and secondary insurance details.
- Provide the contact phone number and date of birth for accurate identification.
- Complete the policy number fields for both primary and secondary insurances.
- Indicate the patient's height and weight, along with any relevant diagnosis information.
- Check appropriate boxes to prescribe necessary equipment or supplies. If you need to delete any supply, indicate it clearly and initial next to it.
- Ensure all prescriptions are filled out correctly, specifying settings and durations where applicable.
- Finally, have the prescribing physician sign and date the form before submission for payment consideration.
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