Вы находитесь на странице: 1из 1

Physician’s Order for Diabetic Testing Supplies

Referral Source: Consultant:


Phone # Phone #
Patient Demographics
Last Name: First Name: M.I. Phone:
Street Address: City: State: Zip:
DOB: Sex: Social Security #:
Insurance Information
Primary Insurance Information:  Medicare  Medicaid Secondary Insurance Information:  Medicare  Medicaid
Name: Name:
Address: Address:
City & Zip: City & Zip:
Phone: Phone:
Policy #: Group #: Policy #: Group #:
Physician’s Information -- The Physician certifies the following: (Complete Items 1 through 5 + sign/date)

1. Physician Order Date: ______________ Duration of Need: ______________ months (99 = lifetime)

2. Patient’s Diagnosis Code(s):  250.00 Non-Insulin  250.01 Insulin  Other Codes: _______________

3. Patient is attempting to control his/her diabetes with insulin injections: Check One Box:  Yes /  No

4. Patient’s testing frequency: Number of Tests per Day = ______________


Note: Medicare & other insurers require an explanation for testing prescribed which is more frequent than: 1 time per day for Non-
Insulin patients and, 3 times per day for Insulin patients. You must check all boxes below which give the explanation for your
request of additional testing for this patient.
 Large fluctuation in daily blood sugar levels  Control of Hypoglycemic states after meals
 Hypertension/High Blood Pressure  Uncontrolled diet
 Other (explain) _____________________________________________________________
5. Supplies prescribed for this patient are as follows (Physician: X-out any item below not prescribed)
Glucose Meter Test Strips Lancet Device Lancets Control Solution Replacement Battery
BY SIGNING BELOW, I state that:
1. I am or was this patient’s treating physician for diabetes mellitus on the effective date of this order.
2. This order accurately reflects this patient’s diagnosis and condition and is substantiated by my medical records.
3. The patient or their caregiver is (or is scheduled to be) trained in the use of the monitor, strips and lancets and is capable of using the
test results to assure the patient’s appropriate glycemic control.
4. I will maintain an original signed copy of this document in my medical records and make it available to Medicare, Medicaid, and
other insurer, First Choice Medical or any authorized agent, if requested.
Physician Name: NPI #:

Address: City: State: Zip:


Contact: Phone: Fax:

Physician Signature: Date:


****PLEASE FAX THIS ORDER TO 704-844-8156****
First Choice Medical
251 N. Trade St. Matthews, NC 28105 (704) 289-3334

Вам также может понравиться