v6 © 07-2008

OSTOMY SUPPLIES

Use your SHIFT LOCK * one patient

per submission

THIS APPLICATION IS USED FOR AN EXISTING PATIENT PROCESSING ONLY.
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)

.      

.
 description stock number qty charge

.
 OSTOMY POUCH - OPEN - DRAINABLE qty $
OSTOMY POUCH - CLOSED - DISPOSABLE qty $
SKIN BARRIER FOR USE WITH POUCH qty $
SKIN BARRIER WIPES PER BOX/50 qty $
SKIN BARRIER LIQUID OR POWDER BY OZ. qty $
SKIN BARRIER SOLID 4 X 4 qty $

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

.

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

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

.

Message or Notes

text box

Click to Submit ->