4102888150 2026

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

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