CMN - NEURO.pdf - Dynasplint Systems, Inc
Transcript of CMN - NEURO.pdf - Dynasplint Systems, Inc
DYN
ASP
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ESCR
IBED
Physician’s Name [Please Print] Phone Number
NPI Number
Street Address City State Zip Code
Physician’s Signature
Primary Diagnosis Code
Tertiary Diagnosis Code
Length of Time Needed:
Resting Hand/Wrist Orthosis
MPO 2000® Active Ankle-Foot OrthosisNeuroFlex™ Restorative™ Knee Orthosis
NeuroFlex™ Restorative™ Elbow Orthosis
RestAir™ Hip Orthosis
Stretch Beyond Your Expectations.®
3 Months 6 Months 12 Months Lifetime Other:
DIA
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ITEM
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PATI
ENT
INFO
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CERTIFICATE OF MEDICAL NECESSITY – NEUROLOGICAL
ACCESSORY ITEMS
Anti-Spasticity Ball Hand/Wrist AttachmentMitt Hand/Wrist AttachmentPadded Palmar Hand/Wrist AttachmentHand Pan C-Cup Hand/Wrist AttachmentUniversal Flat Hand/Wrist Attachment
PHONE e-FAX
PHYS
ICIA
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FORM
ATIO
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A
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SIG
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URE
FAX
TO
NO SUBSTITUTIONS ALLOWED – In my opinion, in accordance with accepted medical practice standards, the above named patient requires the exact Dynasplint® System(s) as dispensed by Dynasplint Systems, Inc., for the diagnosis indicated.
This form is needed to bill the patient’s insurance. Please complete and return.
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Patient currently in a therapy program? Yes Name of Therapy Clinic:
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NEUROLOGICAL DIVISION
SIGN
SALES CONSULTANT
Fax Number
Date
Date of Onset/Surgery/Injury
Quaternary Diagnosis Code
Secondary Diagnosis Code
DATE
WRIST EXTENSION HAND/WRIST ATTACHMENTS
No
Date of Onset/Surgery/Injury
Date of Onset/Surgery/Injury Date of Onset/Surgery/Injury
Kentucky Kollar
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R DS1971 Inversion/Eversion Control System R Other:
Other:
R Replacement Soft Interface Material for: Shoulder Elbow Forearm Wrist Finger Hand(MCP) Knee Ankle
First Name
Start Date of Order (MM/DD/YY) Date of Birth
Last Name
Corporate Headquarters: 770 Ritchie Highway, Suite W-21 Severna Park, MD 21146-3923
Phone: 800.638.6771 / 410.544.9530
FAX TO:www.dynasplint.com
Shoulder Right
Elbow Extension
Forearm noitanipuS
Wrist Extension
Hand (MCP) Flexion
Finger Extension
Knee Extension
Ankle
External Rotation
Extension
Pronation
Plantar Flexion
Flexion
Internal Rotation Abduction Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
51 2 3 4 51 2 3 4
Flexion
Flexion
Flexion
Dorsiflexion
Flexion
Toe ExtensionRight Left
51 2 3 4 51 2 3 4Flexion
Toe