v7 © 11-2008

INHALATIONS SUPPLIES

Use your SHIFT LOCK * one patient

per submission

THIS APPLICATION IS USED FOR AN EXISTING PATIENT PROCESSING ONLY.

NOTE: PLEASE IDENTIFY THE MG's GIVEN TO PATIENT.
Click Here To View the Medicare Q4 2008 Drug Fee Schedule - PDF
Click Here To View the Medicare LCD ( coverage ruling - web page )
PROVIDER INFORMATION
Your Integrated Client Number or your name
IMPORTANT:
PLEASE - At Least Once Per Session of Claim Entry :
YOUR EMAIL ADDRESS:
PRODUCT INFORMATION

.
.      

.Patient Name

(last name first name mi)

.Date of Delivery

.(MM - DD - YY)

.      

.
. Did You Provided the Nebulizer ? yes or rented from another provider

description . ml given charge

ALBUTERAL .083% up to 465 mg / month

We Need MG
 
Albuterol, 0.5 mg

.

mg

$
Albuterol, concentrated form, 1 mg

.

mg

$
Albuterol, unit dose form, 1 mg

.

mg

$

ATROPINE up to 186 mg / month

We Need MG
 
Atropine, concentrated form, per mg

.

mg

$
Atropine, unit dose form, per mg

.

mg

$
Atropine sulfate, up to 0.3 mg

.

mg

$

LEVALBUTEROL up to 232.5 mg / month

We Need MG
 
Levalbuterol HCl, concentrated form, 0.5 mg

.

mg

$
Levalbuterol HCl, unit dose form, 0.5 mg

.

mg

$

IPRATROPIUM BROMIDE up to 93 mg / month

We Need MG
 
Ipratropium bromide non-compounded, unit dose form, 1 mg

.

mg

$

ALBUTEROL AND IPRATROPIUM BROMIDE Not Established

We Need UNITS
 
Duoneb, unit dose form,

.

EA

$
up to 2.5 MG of Albuterol and up to 0.5 MG of IIpratropium Bromide . .

NEBULIZER WITH COMPRESSOR ( Medicare Capped Rental Item )

$

Only Non-Participating Medicare Providers or claims for other than Medicare patients may use the providers price

Participating Providers - tell us what you want - but click here to see what they pay!

If check boxes can't be used, enter product info and QTY.

WE NEED THE MG'S GIVEN TO THE PATIENT

Also use this box for Client Name & Number if needed.

text entry area

.

.

.ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim *

.YES NO * ( only non participating Medicare providers may check NO )

.
Make This Patient A Diary Billing ? YES. NO ( Look on the Healthcare Menu for more information )

Click to Submit ->