Wound Care Medical Necessity Assessment Form Patient's Name* First Last Patient's Date of Birth* MM slash DD slash YYYY Appointment Date* MM slash DD slash YYYY Diagnosis Code* HS Stage* Type of Occlusive Bandage being used for autolytic debridement:* Primary Bandage (A6021 or A6023): ColActive Plus AG with Silver Secondary Bandage (A6196-A6198): Zetuvit Plus Non-Border Super Absorbant Dressing OR (A6252-A6253): Sorbalux ABD Absorbant Dressing Patient Wounds* Location Descriibe wound location Size: Length, Width, Depth(cm) [length], [width], [depth] Drainage: Mild - 1 Moderate - 2 Heavy - 3 Thickness: Partial - 1 Full - 2 Color Clear - 1 Serosanuineous - 2 Bloody - 3 Yellow - 4 Brown - 5 Other: - Describe Odor No - 1 Yes - 2 Tunneling/Undermining No - 1 Yes - 2 Primary Bandage Size [4in x 4in] - 1 [7in x 7in] - 2 Secondary Bandage Size 16in2-48in2 48in2+ 1 Location2 Size3 Drainage4 Thickness5 Color6 Odor7 Tunneling8 Primary Bandage Size9 Secondary Bandage Size10 Dressing Changes per day Physician Signature*Date* MM slash DD slash YYYY