Wound Care Supplies Form

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THM Inside Rep Name

First Last

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THM Inside Rep Phone

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THM Inside Rep Email

Representative Information

Name

First Last

Phone

Patient Information

Patient Name(Required)

First Last

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient Phone(Required)

Patient DOB(Required)

Physician Information

Physician Name(Required)

First Last

Physician Address(Required)

Street Address Address Line 2 City State ZIP Code

Physician Phone(Required)

Physician Fax(Required)

Physician NPI#(Required)

Patient Insurance Information

Medicare #

Patient Insurance Name(Required)

Patient Insurance Phone(Required)

Patient Insurance Policy #

Patient Insurance Group #

Patient Medical Supplies

Please Select Correct HCPCS Code and Product(Required)

A6021: Collagen Wound Dressing 16 sq in or less ... Qty/Mo 30 x 2 wound changes

A6023: Collagen Wound Dressing over 48 sq in ... Qty/Mo 30 x 12 wound changes

A6252: Absorbant Wound Dressing 16in to 48 sq in ... Qty/Mo 30 x 2 wound changes

A6253: Absorbant Wound Dressing over 48 sq in ... Qty/Mo 30 x 12 wound changes

Signature(Required)

I confirm that I am the physician treating this patient and have seen this patient within the last six months to evaluate urological condition. I can/will provide documentation from the patient’s medical record to support normal or increased frequency on request by Trust Home Medical for Medicare/Insurer audit purposes immediately. All the information contained in this Physician’s Order accurately reflects that patient’s urological condition and the regimen I have prescribed. Trust Home Medical will send a 90 day supply every 90 days after confirming with the patient that more supplies are needed. My Medical records for the patient substantiate the prescribed utilization of products. I will maintain a copy of this signed original Physician’s Order in the patient’s medical record file.