ࡱ> WYV% bjbj%% (LGG l&&&&&&&:    Ld l:> :*<W-//////$4 T"S&S&&&&--&& ɼ: j0>""::&&&&SPECIAL CARE HOME OXYGEN AND PHARMACY SERVICES 1301 N. PLANO RD RICHARDSON TX 75081800-644-2270 972-644-2273 Fax 972-783-0848 Nebulizer and Respiratory Medications Order Form Patient Name  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip  FORMTEXT      Phone  FORMTEXT      DOB  FORMTEXT      HICN #  FORMTEXT       FORMCHECKBOX Yes  FORMCHECKBOX  No Use of a metered Inhaler has been considered and ruled out as a primary method of treatment?  FORMCHECKBOX Yes  FORMCHECKBOX  No Is a metered dose Inhaler being used concurrently with this therapy? If yes, Why? ________________  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is this medication being administered via a nebulizer compressor?Start Date  FORMTEXT      End Date  FORMTEXT      Length of Need 12 moDiagnosis Code(s)  FORMTEXT      Prognosis  FORMCHECKBOX Good  FORMCHECKBOX Fair  FORMCHECKBOX  Poor  FORMCHECKBOX  Nebulizer Machine (Diagnosis must be 491.0-505 for Medicare Plans) Has this patient had this equipment before?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, How long?  FORMTEXT       COMMERCIALLY AVAILABLE MEDICATIONS FOR INHALATION (Medicare Plans Only)  FORMCHECKBOX  Albuterol 0.083% vial: 2.5mg in 3ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Brovana( 15mcg in 2ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Perforomist ( 20mcg in 2ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Duoneb( Alb 0.083% and Ipra 0.02% vial: in 3ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Ipratropium 0.02% vial: 0.5mg in 2.5ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Pulmicort( 0.25mg in 2ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Other: ________________________________________ # of Vials  FORMTEXT        FORMCHECKBOX  Other: ________________________________________ # of Vials  FORMTEXT       PHARMACIST COMPOUNDED MEDICATIONS FOR INHALATION (Medicare Plans Only)  FORMCHECKBOX  Budesonide 0.5mg in 3ml saline # of Vials  FORMTEXT        FORMCHECKBOX  Formoterol 12mcg/Budesonide 0.5mg in 2.5ml saline # of Vials  FORMTEXT       Dispensing Quantity: 1-month supply provided unless noted ___________________________ Unless otherwise indicated a generic substitute will be provided when available or indicate brand name medically necessary. Direction (Sig): ________________________________________ Refill PRN 12 Months _____ Other _____Physicians Signature: ________________________________________________________________________ I certify that the information contained herein is a true and correct verification of my verbal or written order and that my medical records support the medical need for the items prescribed above.Physician s Name  FORMTEXT      UPIN  FORMTEXT      NPI  FORMTEXT      Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip  FORMTEXT      Phone  FORMTEXT      Fax  FORMTEXT      Nebulizer Supplies needed A7003 Disposable Neb Kit (max -- 2/mo) (includes tubing, mouthpiece, cup) A7005 Non-disposable Neb Kit (max -- 1/6mo) (includes tubing, mouthpiece, cup)A7004 Disposable Neb Cup (max -- 2/mo)A7013 Disposable Filters (max -- 2/mo) A7015 Aerosol Mask (max -- 1/mo)A4621 Trach Mask or Collar (max -- 1/mo) ^tv "$02FHJTVX`bvxz۱ۤۗۊj5CJU\j`5CJU\j5CJU\jv5CJU\j5CJU\mHnHuj5CJU\ 5CJ\j5CJU\CJB*OJQJphCJ 5CJ \2^tv$0X`V$$Ifl*+04 la$If  !$If$a$$a$`$i8^^^^^^  !$If$$Ifl\U"%*: 04 la$If "$&(DFHRTprtz+,-23ABCHҵjCJUjCJUCJjCJUjCJUCJ jCJUj45CJU\j5CJU\CJ 5CJ\j5CJU\mHnHuj5CJU\jL5CJU\0$& |r| $If$If|$$IflF D*XXX0    4 la  % & 0 1  " 6 8 : D F H f r   " . ˾ѮˡѮ˚ˍѮyj0CJUjCJUjH5CJU\ CJmH sH j5CJU\j5CJU\mHnHuj`5CJU\ 5CJ\j5CJU\CJCJjCJUCJ jCJUjxCJU/  %  H f r \  $$Ifa$$IfV$$Ifl*+04 la . 0 L N P Z ^ ` b ~   p r       HJ^ܵܫ臄wpn>* j>*Uj U jUCJCJj5>*U\mHnHujz 5>*U\ 5>*\j5>*U\j 5U\j 5U\ 5CJ \j 5U\5\j5U\CJ jCJUCJ jCJU)\ ^ `     p\WUUWWSUU$a$$$Iflr& *:  04 la ^`blnpr  <>@\^JL`bj>*UjUj*>*Uj Uj> >*U jj UjR >*U jj U jU>*j>*UmHnHu j>*Ujf >*U7pr"F<=$If$a$bdnprt "$@BD  FHdfhھڬړj>*UjPUCJ >*CJj>*UjdUj>*UjxUj>*U>* jjU jUj>*UmHnHu j>*U:<= (*>@BLNPXZnpr|~¿x¿j5CJU\j5CJU\j5CJU\mHnHuj(5CJU\ 5CJ\j5CJU\CJ5\ 5CJ\CJ>*CJj>*UmHnHuj>*U>* j>*U jUj<U.6(PX,\  !$If$IfX$$Ifl*+064 la  *R{{{{{{{{$If~$$IflFi*V 3 06    4 la  *,@BDNPRT`bvxzҵҨҤҗҊҤmH sH j5CJU\j`5CJU\5\j5CJU\jt5CJU\j5CJU\CJ 5CJ\j5CJU\mHnHuj5CJU\j5CJU\4RT`nhhhh$If$$Ifl\i#*V 064 la<  !$Ifk$$Ifl0*V064 la9a@$If  !$Ifl$$Ifl40/^*//0^*64 lalab5\ab,$Ifm$$Ifl0/^*//0^*64 lalk$$Ifl0/^*//0^*64 lal& 001/ =!"# $ %vDText22vDText20tDText2vDText19vDText18tDText3tDText4tDText5tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDText6tDText7tDText8tDeCheck7tDeCheck8tDeCheck9vDeCheck23vDeCheck24vDeCheck25vDText23vDeCheck22vDText21vDeCheck11vDText21vDeCheck16vDText21vDeCheck13vDText21vDeCheck12vDText21vDeCheck15vDText21vDeCheck20vDText21vDeCheck21vDText21vDeCheck21vDText21vDeCheck21vDText21tDText9vDText10vDText11vDText15vDText12vDText17vDText16vDText13vDText14 i8@8 NormalCJ_HaJmH sH tH <@< Heading 1$$@&a$ 5CJ \8@8 Heading 2$$@&a$5\0@0 Heading 3$@&CJ06@6 Heading 4$@& 5CJ\F`F Heading 5$$@&a$5B* CJ\ph<A@< Default Paragraph Font,@, Header  !."@. 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