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	.Patient Name (last name first name mi)		.Date of Delivery .(MM - DD - YY)
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. 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

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.	.ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim * .YES NO * ( only non participating Medicare providers may check NO )
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Make This Patient A Diary Billing ?

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