Receta Medica
Enviado por maricruz0805 • 17 de Abril de 2015 • 580 Palabras (3 Páginas) • 177 Visitas
Patient Name: Date: ________________
Address: _________________________________________
Phone number: _ Date of Birth: _________
Medi-cal Info: ________________ ID#: _____________________
RX: Incontinence Supplies
□ Youth Briefs/ T4533 QTY: 192 Use_____ per day
□ Small Briefs/ T4521 QTY: 192 Use_____ per day
□ Medium Briefs/ T4522 QTY: 200 Use_____ per day
□ Large Briefs/ T4523 QTY: 216 Use_____ per day
□ Extra Large Briefs/T4524 QTY: 180 Use_____ per day
□ XX-Large Briefs/T4524 QTY: 144 Use_____ per day
□ Protective Underwear/Pull-Up’s Sz:____QTY: 120 Use_____ per day
□ Undergarments/T4535 (95430 CS/120) QTY: 180 Use_____ per day
□ Liners/T4535 (At Ease- 90030-24 CS/180) Use_____ per day
□ Liners/T4535 (90200SAP CS/180) QTY: 180 Use_____ per day
□ Liners/T4535 (Dignity Liner 26955) QTY: 175 Use_____ per day
□ Liners/T4535 (Dignity Plus 30071) QTY: 175 Use_____ per day
□ Liners/T4535 (40068 Spartan) QTY: 175 Use_____ per day
□ Underpads/T4541 (box of 100) QTY: 100 Use_____ per day
□ Panties/T4536 QTY: 2
□ Ca-Rezz Cream/A6250 (250/gms per jar) QTY: 2
□ Ca-Rezz Wash/A4335 (237/mls per bottle) QTY: 4 Refills: 12
□ Waterproof Sheeting/T4537 QTY: 2
DX 1: □ Urinary Incontinence ICD-9 788.30
□ Bowel/Fecal Incontinence ICD-9 787.60
*Must have a secondary diagnosis*
2nd DX: ___________________________________ ICD-9: ___________
Physician Name: ____________________________________________
Physician Address: ___________________________________________
Physician
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