v5 © 12-2006

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 $
ADH TAPE, ALL TYPES qty $
OTHER qty $
OTHER qty $

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

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

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

IT IS RECOMMENDED THAT YOU INCLUDE THE MANUFACTURER'S STOCK NUMBER FOR ALL OSTOMY ITEMS TO ENSURE PROPER IDENTIFICATION AND CODING :

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 ->