FAX COVER      FACE SHEET

UPIN SEARCHDR. MED LICENSEICD-9 CODES

 

          FREQUENTLY    ASKED   QUESTION

CELL PHONE MESSAGING                                                OFFICE TOOLS

*****FORMS PAGE (internal use only)*****

INITIAL FORMS:  (NEW CUSTOMER)

Intake Form  |  Physician Order Form  |  Physician Letter | RX Request  | Insurance Verification Form |

Cover Letter CMN |   WE MISS YOU | Wheelchair Check List | MAE Order Form |

Medicare Chart |

SALE FORMS:

Medicare may not Pay Custom Order Agreement Rental Form (front side) Rental (back side) |

Promissory Note  | Warranty | Non-Covered Items | Consumer Finance |

SERVICE FORMS:

Purchase Order Maintenance Checklist | Service Test | Repair Questionaire |

EVALUATION FORMS:

Medicaid Eval Form | Powered Wheelchairs | Modular Ramps | In Home Eval |

| Environmental Assessment | FUNCTIONAL MOBILITY EVALUATION | Reason for Change |

Seating Simplified              Power Wheelchair Codes       Lift Chair Guide                   Manual Wheelchair Guide    Scooter Guide                      Power Wheelchair Guide       Wheelchair Seating Guide Quantum Rehab Guide    Repair Guide                 Capped Rental Guide       CMN Guide                       1500 Form Guide             ABN Guide                 Advanced Deternmination   New Power Wheelchair Codes Power Wheelchair Overview

 

                               

 

| New Physician's Letter | Physicians Order-Manual W/C | Physicians Order-Power W/C |

| MAE Order Form | Common MRADLS | Home Assessment |

SEATING FORMS:

Contour U Order Form  |  Silhouette Order Form  

MEDICARE FORMS:  REGION A  |  REGION B  |  REGION C  REGION D                  

COVERAGE ISSUES FOR DMEABN FORM  |

CMNS:

Beds Support Surfaces  | Wheelchairs-Manual  |  Wheelchairs Power Power Operated Vehicles

Lift Chairs Section C-continue form

DELIVERY FORMS:  All Delivery Forms

Accepted Liability  |  Assignment of Benefits Check List  |  Program Power Chair  | Supplier Notice

Same or Similar  |  Rent or Purchase  |  Signature on File | Equipment Warranty |

MISC. FORMS:

Complaint Form Consignment Agreement  |  Return  |  Sales Tax  | PTOT list  | Fax Cover

NEW EMPLOYEES

Application for Employment | Service Tech Questions

Vehicle Policy  |  Phone Policy  |  Form W-4  |  Form I-9  |  Affidavit of Good Moral Character

Pledge of Confidentiality  |  Confidentiality and Non-Disclosure  Change of Password

HIPAA FORMS

Employee Training Log  |  Patient Request of PHI  |  Request for Restriction of PHI

Request for Ammendment  Medical Record Ammendment-Correction Form

Disclosure of Medical Information  |  Patient's Requests for Restriction  |

Patient Complaint Log  |  Authorization to Use and/or Disclose PHI  |

Consent to Use and/or Disclose PHI  |  Acknowledgement of Notice |

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                                                                LINKS:

 REPAIR / SERVICE-On site equipment

VGM  |  MEDICAID  |  MED-WAIVER  |  MEDICARE SITE  |  MEDTRADE

DELMARVA | MAXIMUS

GOVERNMENTAL LEGISLATION

Centers for Medicare & Medicaid Services 7500 Securty Blvd. Baltimore, MD 21244 (877) 267-2323

MED Capitol Connection

Office of the National Ombudsman 409 3rd Street, SW MC 2120 (888) 734-3247

Small Business Adminstration 403 3rd Street S.W. Washnington, DC 20416 (800) U-ASK-SBA

US Department of Health & Human Services, Washington DC (877) 696-6775

US Department of Justice Disability Rights Section Washington D.C. (202) 514-2000

REHABILITATION

American Occupational Therapy Association (AOTA) (301) 652-2682

Association for Driver Rehabilitation Specialists (ADED) (800) 290-2344

National Registry of Rehabilitation Technology Suppliers (NRRTS) (512) 267-6832

National Rehab Network (806) 793-8421

National Rehabilitation Association (NRA) (703) 836-0850

Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) (703) 524-6686

US Rehab (800) 987-7342

 

 

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