Urology Order Form Byram Healthcare

Urology order form byram healthcare

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 Name (Last, First):__________________________________________ }Date of Birth (MM/DD/YY):_________________
}City:_________________________________________________ State:______________ Zip Code:___________________
}Phone Number:_____________________________________ Mobile Number:____________________________________
Language: q English q Spanish q Other:__________________ Email:___________________________________________
}Primary Insurance:__________________________________ ID#________________ Phone:______________________
Secondary Insurance:_________________________________ ID#________________ Phone:______________________
}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:______________________________
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
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.)
Incontinence Items Size/Type Frequency of Use Qty/Mo
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: 1-800-364-6057
This 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 information
protected 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 or
copying 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, 120
BLOOMINGDALE 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

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Frequently Asked Questions

Why choose byram healthcare for urology care?

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.

How do i contact byram customer service?

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.

What is the icd 10 code for urology order form?

Urology Order Form Title Uro Fax Form ICD10 0715.indd Created Date 7/16/2015 11:27:23 AM

What is byram in network coverage?

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.