cmn - neuro.pdf - dynasplint systems, inc

DYN

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IBED

Physician’s Name [Please Print] Phone Number

NPI Number

Street Address City State Zip Code

Physician’s Signature

Primary Diagnosis Code

Tertiary Diagnosis Code

Length of Time Needed:

Resting Hand/Wrist Orthosis

MPO 2000® Active Ankle-Foot OrthosisNeuroFlex™ Restorative™ Knee Orthosis

NeuroFlex™ Restorative™ Elbow Orthosis

RestAir™ Hip Orthosis

Stretch Beyond Your Expectations.®

3 Months 6 Months 12 Months Lifetime Other:

DIA

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OSI

SAT

TACH

MEN

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CCES

SORY

ITEM

(S)

PATI

ENT

INFO

RMAT

ION

CERTIFICATE OF MEDICAL NECESSITY – NEUROLOGICAL

ACCESSORY ITEMS

Anti-Spasticity Ball Hand/Wrist AttachmentMitt Hand/Wrist AttachmentPadded Palmar Hand/Wrist AttachmentHand Pan C-Cup Hand/Wrist AttachmentUniversal Flat Hand/Wrist Attachment

PHONE e-FAX

PHYS

ICIA

N IN

FORM

ATIO

N

A

ND

SIG

NAT

URE

FAX

TO

NO SUBSTITUTIONS ALLOWED – In my opinion, in accordance with accepted medical practice standards, the above named patient requires the exact Dynasplint® System(s) as dispensed by Dynasplint Systems, Inc., for the diagnosis indicated.

This form is needed to bill the patient’s insurance. Please complete and return.

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Patient currently in a therapy program? Yes Name of Therapy Clinic:

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NEUROLOGICAL DIVISION

SIGN

SALES CONSULTANT

Fax Number

Date

Date of Onset/Surgery/Injury

Quaternary Diagnosis Code

Secondary Diagnosis Code

DATE

WRIST EXTENSION HAND/WRIST ATTACHMENTS

No

Date of Onset/Surgery/Injury

Date of Onset/Surgery/Injury Date of Onset/Surgery/Injury

Kentucky Kollar

L

R DS1971 Inversion/Eversion Control System R Other:

Other:

R Replacement Soft Interface Material for: Shoulder Elbow Forearm Wrist Finger Hand(MCP) Knee Ankle

First Name

Start Date of Order (MM/DD/YY) Date of Birth

Last Name

Corporate Headquarters: 770 Ritchie Highway, Suite W-21 Severna Park, MD 21146-3923

Phone: 800.638.6771 / 410.544.9530

FAX TO:www.dynasplint.com

Shoulder Right

Elbow Extension

Forearm noitanipuS

Wrist Extension

Hand (MCP) Flexion

Finger Extension

Knee Extension

Ankle

External Rotation

Extension

Pronation

Plantar Flexion

Flexion

Internal Rotation Abduction Left

Right Left

Right Left

Right Left

Right Left

Right Left

Right Left

Right Left

51 2 3 4 51 2 3 4

Flexion

Flexion

Flexion

Dorsiflexion

Flexion

Toe ExtensionRight Left

51 2 3 4 51 2 3 4Flexion

Toe