Balanced Scorecard (BSC) of Norwalk

Topics: Pleural effusion, Patient, Physician Pages: 5 (720 words) Published: December 2, 2013
Patient Insurance Information
PleurX® Drainage Kits

Patient Information: Complete the following section or attach the patient’s face sheet. Patient Name: Last__________________________________ First______________________________________ M.I.____________ Patient Phone:______________________________________________________________________________________________________ Alternate Contact Name:_______________________________________________________ Phone:_____________________________ Address:____________________________________________________________________________________________________________ City:_______________________________________ State:_______________________________ZIP:____________________________ Insurance Information:

***Complete insurance information is critical for timely shipment of supplies*** Primary Insurance:___________________________________ Phone:_______________________________________________________ Policyholder:________________________________________

ID #:_________________________________________________________

Employer or Group Name:____________________________

Group #:_____________________________________________________

Secondary Insurance:________________________________ Phone:_______________________________________________________ Policyholder:________________________________________

ID #:_____________________

Group #:_________________________

Hospital Information:
Hospital:____________________________________________________________________________________________________________ Placement Date:_____________________________________

Discharge Date:_______________________________________________

Name of PleurX Contact at Physician’s Office:___________________________________________________________________________ Name of Referring Physician:__________________________________________________________________________________________ Patient Care: Complete this section. If applicable, may reduce patient’s supply cost. Vacuum Bottle Size:

Patient is being discharged to:

Home with no nurse in home

Hospice

1000 ml

Nurse in home (HHA/VNA)

500 ml

Skilled Nursing Facility (SNF)

Number of bottles discharged with: __________
Care Start Date:___________________________________

Name of Provider:_______________________________________________

Provider Contact:__________________________________ Phone:_________________________________________________________

***Please fax completed forms to: 877.307.6350***

I would like confirmation the prescription was received.

Contact me via

Phone: _________________________________ or

E-Mail: ___________________________________________

Preserve original order or mail to:
Edgepark Medical Supplies
1810 Summit Commerce Park
Twinsburg, OH 44087
Questions? Call the PleurX specialists: 877.307.8033
Notes: ___________________________________________________________________________________________________________ This prescription or the information contained herein may be shared with or reported to CareFusion, the product manufacturer, for quality purposes to ensure that the necessary resources are available to service patients using the PleurX product line. Such information is furnished in compliance with HIPAA to allow for the best treatment of the patient. Nonetheless, if you or your patient do not wish for this prescription or information to be shared with CareFusion, please call 877-307-8033 and a PleurX Specialist at Edgepark Medical Supplies will assist with this request and ensure that the information is not shared.

rev 02-11

CareFusion or authorized representative (Edgepark Medical Supplies) PleurX is a trademark and/or registered trademark of CareFusion Corporation, or one of its subsidiaries.

361-24111

Detailed Written Order
PleurX® Drainage Kits
Section A:
Patient...
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