Phone: 207-784-3700

325.2

Is Wound Debrided? Yes Patient Currently Being Seen by Home Health Agency? Yes NoIf YES, Name of Agency:__________________________________________________

Please include the Please include the Patient Demographic SheetPatient Demographic Sheet with this order form with this order form*Patient progress notes to support medical necessity are required in order for insurance to approve claim*Patient progress notes to support medical necessity are required in order for insurance to approve claim

DRESSING INFORMATION

Dressing Use Dressing TypeDressing

SizeDrainage

Type Frequency Wound 1

Wound 2

Wound 3

Wound 4

Primary Secondary Collagen Daily Primary Secondary Silver Collagen Daily Primary Secondary Calcium Alginate Mod/Heavy Daily Primary Secondary Silver Alginate Mod/Heavy Daily Primary Secondary Calcium Alginate Rope Mod/Heavy Daily Primary Secondary Foam Mod/Heavy 3 x Week Primary Secondary Bordered Foam Mod/Heavy 3 x Week Primary Secondary Silver Foam Mod/Heavy 3 x Week Primary Secondary Hydrogel No/Min 3 oz Primary Secondary Adaptic Daily Primary Secondary Gauze Daily Primary Secondary Kerlix AMD/Bioguard Daily Primary Secondary Conforming Roll Gauze Daily Primary Secondary Tubular Dressing Daily Primary Secondary Tape Daily Primary Secondary ABD Mod/Heavy Daily

OTHER PRODUCTS

BY SIGNING BELOW, I AUTHORIZE the use of this document as an order, and I certify that the above prescribed supplies are medically necessary and reasonable.

Physician Name:________________________________________________________________ NPI #:______________________________ Phone Number:____________________________________________ Fax Number:_____________________________________ Physician Signature:_____________________________________________________________________ Date:___________________

Wound Type Length Width Depth Thickness DrainagePartial Full None Min Mod HeavyPartial Full None Min Mod HeavyPartial Full None Min Mod HeavyPartial Full None Min Mod Heavy

Please fax this form to Bedard Medical Supplies at 207-784-7992

WOUND DRESSING ORDER FORM

1. Patient Information Patient Name:___________________________________________________________________________________ DOB:______________ Phone #:_______________________ Facility:________________________________________________ Fax #:_______________________

2. Clinical Wound Information

Length of Need:____________

Refills:____________________

3. Physician’s Order

4. Diagnosis Information

ICD-10 Code Description

5. Prescriber Information