v5 © 12-2006

SURGICAL DRESSINGS

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)

.      

.
 NOTE: very specific conditions must exist for all supplies to be covered
. Decubitus Ulcer Present ? yes single ulcer multiple sites
description

MFG #
 qty charge

.
 ADHESIVE TAPE ALL TYPES, PER 18 SQ IN qty $
GAUZE, NON-ELASTIC, STERILE, ALL TYPES, qty $
GAUZE, NON-IMPREGNATED NON-STERIL PAD qty $
GAUZE, NON-IMPREGNATED STERILE SIZE 16 qty $
SKIN BARRIER WIPES PER BOX/50 qty $
STERILE SALINE IRRG SOL, 1000 ML qty $
SURGICAL STOCKINGS, BELOW KNEE, EACH qty $
HYDROCOLLOID DRESSING, WOUND COVER 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 ->