PATIENT NAME: ________________________________________ ORDER START DATE: _____/_____/______

PATIENT PHONE: (_____)_________________________________ PATIENT DOB: _____/_____/______

REFERRAL FACILITY: _____________________________________ CITY: _________________ STATE: ______

REFERRAL PHONE: (_____)________________________________ FAX: (_____)_________________________

(SECTION 1) GENERAL INTAKE INFORMATION

WOUND 1 WOUND 2 WOUND 3

DESCRIPTION/ICD-10

WOUND EXUDATE NONE LOW MOD HVY NONE LOW MOD HVY NONE LOW MOD HVY

WOUND LOCATION ________________ LT RT ________________ LT RT ________________ LT RT

WOUND SIZE ( L x W x D ) x x (cm) x x (cm) x x (cm)

HAS THE WOUND BEEN DEBRIDED? YES, DATE ___/___/___ NO YES, DATE ___/___/___ NO YES, DATE ___/___/___ NO WOUND THICKNESS FULL PARTIAL FULL PARTIAL FULL PARTIAL

(SECTION 2) WOUND ASSESSMENT

(SECTION 3) WOUND CARE PRODUCTS

(SECTION 6) AUTHORIZATIONS

INSURANCE COVERAGE DOES THE PATIENT HAVE A DEBRIDED OR SURGICALLY CREATED OPEN VENOUS STASIS ULCER?

PLEASE FILL OUT THE ENTIRE FORM AND INCLUDE THE PATIENT’S DEMOGRAPHICS TO AVOID DELAYS.

SUPPLIER SIGNATURE:______________ ___/___/___(DATE)

GRADIENT COMPRESSION

V.4(07-2019)

WOUND 1

SIZE FREQUENCY OF CHANGE

QUANTITY

(SECTION 7) PROVIDER SIGNATURE

THE PATIENT IS REQUESTING COORDINATION OF CARE YES NO

(THE PATIENT HAS CHOSEN PRISM TO ASSIST IN PROVIDING THE REQUESTED CARE BY EITHER; PROVIDING PRODUCT, VERIFYING INSURANCE BENEFITS, BILLING FOR SERVICE(S) OR COORDINATING CARE SHOULD DIRECT SERVICE NOT BE AN OPTION.)

VERBAL ORDER: YES NO (IF YES, INDICATE REFERRING PROVIDER AND ASSISTING CASE MANAGER)

CASE MANAGER ASSISTING WITH VERBAL ORDER:

______________________________________(PRINT NAME)

PRODUCTS

Items designated by an *asterisk require FULL thickness for insurance coverage.

SALINE GLOVES COTTON TIP APPLICATORS SKIN PREP ADHESIVE REMOVER STERILE WATER

(SECTION 4) SUPPLY ASSESSMENT (SECTION 5) NOTES

SINGLE LAYER STOCKING LT RT

DUAL LAYER STOCKING LT RT

COMPRESSION WRAP LT RT

OTHER:________________ LT RT

(CALF) _____LT_____RT

(ANKLE) _____LT_____RT

(LENGTH)_____LT_____RT

30-40 mmHg LT RT

40-50 mmHg LT RT

MONTHLY LT RT

OTHER:_______ LT RT

MEASUREMENTS (cm) COMPRESSION LEVEL FREQUENCY OF CHANGE

ADDITIONAL ITEMS

COMPRESSION LEVEL

DOES THE PATIENT CURRENTLY HAVE ANY OF THE REQUESTED PRODUCT(S) AT HOME? YES NO IF YES, LIST THE QUANTITY REMAINING OF EACH PRODUCT THE PATIENT CURRENTLY HAS IN THE NOTES SECTION.

WWW.PRISM-MEDICAL.COM PHONE: (888) 244-6421

FAX: (800) 975-6321

WOUND 2

SIZE FREQUENCY OF CHANGE

QUANTITY

WOUND 3

SIZE FREQUENCY OF CHANGE

QUANTITY

YES NO

PROVIDER’S NAME:______________________________________________________

NPI:___________________________________________________________________

SIGNATURE:____________________________________ ____/____/____(DATE)

*(If the PROVIDER listed above is best reached at a location other than the referring facility detailed in Section 1, please provide the PROVIDER’S contact information below.)

PROVIDER PHONE: (________)______________________________________________

PROVIDER FAX: (________)______________________________________________