Physician's Order - Life Care Medical

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
DOB*
Sex*
- Female
- Male
Diagnosis
ICD-10 CODE*
Length of Need
Last Face-to-Face Date
Medical Records Included
- Yes
- No
Upload Medical Records
Weight
Height
Reason for Need/Medical Necessity
Specific Supplied Ordered*
I, the undersigned, certify that the above prescribed equipment/supplies is medically necessary as part of my treatment for this patient. In my opinion, the equipment prescribed is reasonable and necessary for accepted standards of medical practice and treatment of this patient's condition and has not been prescribed as "convenience equipment".
Physician Name*
Phone*
Fax*
Physician Address*
Street Address City State / Province / Region ZIP / Postal Code
NPI*
**Frequency of Use***
Date*
MM
DD
YYYY
Physician Signature*