File Name: urology-order-fax-form.ashx
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Please fax to: 1-866-992-6331 HB Email: [email protected] Referral Number: 1234567890 Referral Name, Address and Phone: Urology Order Form} Required Information q Face Sheet Attached PATIENT INFORMATION: }Patient Name (Last, First):__________________________________________ }Date of Birth (MM/DD/YY):_________________ }Street:______________________________________________________________________________________________ }City:_________________________________________________ State:______________ Zip Code:___________________ }Phone Number:_____________________________________ Mobile Number:____________________________________ Language: q English q Spanish q Other:__________________ Email:___________________________________________ }Primary Insurance:__________________________________ ID#________________ Phone:______________________ Secondary Insurance:_________________________________ ID#________________ Phone:______________________ PLAN OF CARE: }Start Date:__________________ }Length of need: 99=Lifetime unless otherwise indicated. q Other:_________ Months Does patient have UTI history (at least 2 within last 12 months)? q Yes* q No * If yes, and the patient’s insurance provider follows Medicare guidelines, fax a copy of lab work and Latex Allergy? q Yes q No supporting documentation along with this form
}ICD10 Diagnosis: q Enuresis not due to a substance or known physiological condition F98.0 q Neuromuscular dysfunction of bladder, unspecified N31.9 q Retention of urine, unspecified R33.9 }q Primary/Causal Diagnosis:______________________________ RECOMMENDED SUPPLIES: Urological Items Brand Preference French Size/Length Frequency of Use Qty/Mo Intermittent Catheters q Straight q Coudè q Hydrophilic q Silicone q Red Rubber q PVC Closed System Intermittent Catheter q Straight q Coudè (includes Closed System Intermittent Catheter insert. suppl.) q Straight q Coudè Male External Catheters Leg Bag Foley Catheter q Two-Way q Three-Way q Latex q Silicone Foley Insertion Trays q with bag q without bag Lubricant q packets q tube (Medicare covers one packet per catheter.) Other Incontinence Items Size/Type Frequency of Use Qty/Mo Diapers Pullups Liners Other name, npi# name, npi# name, npi# q q q q q q q q q q q q Licensed Healthcare Provider’s Acknowledgement: My signature below denotes that the statements above are true, accurate and complete, to the best of my knowledge. I certify that the patient is being treated by me and I have seen the patient in the last 6 months. The patient is informed that s/he will be contacted by Byram Healthcare regarding coverage for items ordered. I authorize the prescription of the supplies above and my signature aligns with the pre-printed name
} Licensed Healthcare Signature stamps are NOT acceptable Date stamps are NOT acceptable Provider’s Signature: ____________________________________________________________ }Date:_________________For more information, please call: 1-800-364-6057This fax communication may contain Protected Health Information (PHI). Protected Health Information is personal and sensitive Information related to a person’s health care. This fax may also may include informationprotected by State or Federal regulations. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohibited
Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law
This document contains privileged and confidential information intended only for the use of the addressee(s) listed. If you are not the intended recipient of this document, you are hereby notified that any dissemination orcopying of this document is strictly prohibited. If you have received this document in error, please notify us immediately by telephone and return the original via the U.S. Postal Service, to: BYRAM HEALTHCARE, 120BLOOMINGDALE RD STE 301, WHITE PLAINS, NY 10605. Thank you.©2018 Byram Healthcare. All rights reserved
Urology Order Form. Title: Uro Fax Form ICD10 0715.indd Created Date: 7/16/2015 11:27:23 AM
Byram Healthcare provides urology care solutions to fit your needs. Byram can help you choose the right urology supplies and keep you informed about the latest product innovations. We carry one of the largest urologic catheter selections from all of the top manufacturers.
You can also review our Frequently Asked Questions. You may also call us at 1-877-902-9726 (1-877-90-BYRAM). Our Customer Service Representatives will be happy to assist you with placing your order or answering any questions, Monday – Friday: 8:30 AM - 7:00 PM, and Saturday: 9:00 AM - 1:00 PM, local time in the continental United States.
Urology Order Form Title Uro Fax Form ICD10 0715.indd Created Date 7/16/2015 11:27:23 AM
You may also view the video with open captions. Byram is a contracted provider covering 260+ million lives. Our broad in-network coverage aims to give you a better financial experience with lower, in-network co-payments and deductibles.