Cameron Company Section BreakName First DOB Date Format: DD slash MM slash YYYY SSN First Address Street Address PhonePatient Insurance and Policy# First Initial Date: First Lenth of Need First Dx Code(s): First Ht: First Wt: First WheelchairsSize: First Width: First Height: First Standard Wheelchair(K0001)1 per month Lightweight Wheelchair(K0003) 1 per month Repairs/Loaner PT/OT Mobilty E Evaluation Wheelchairs Accessories Ganeral Back Cushion(E2611/E2612) General Seat Cushion(E2601/E2604) Skin Protection Seat Cushion(E2603/E2604) Positioning Seat Cushion(E2605/E2606) Skin Protect & Positioning Seat Cush(E2607/E2608) Adjustable Height Arm Rest(E0973) Elevated Leg Rests(K0195) Anti-Tippers(E0971) Brake Extensions(E0961) Hospital Bed/Mattresses/Accessories Standerd Semi-Electric Bed(E0261)1 per month Bariatric Semi-Electric Bed(E0301)1 per month Low Air Loss Mattress(E0277)1 per month Gel Overlay Mattress(E0185) Innerspring Mattress(E0271) Hoyer Lift(E0630)1 per month Hoyer Lift Sling(E0621) Trapeze Bar-Attach to Bed(E0910)1 per Month Respiratory(Oxygen/Nebulizers) Nebulizer w/Compressor (E0570)1 per month Disposable Neb Kit (A7003)2 per month Non-Disposable Neb Kit (A7005)2 per 6 month 02 Concentrator Liter Flow(E1390)1 per month Portable Qxygen tanks(E0431)1 per month HomeFill Concentrator (K0738)1 per month Conserving Device (X9999)1 per month Over Night Pulse Ox Walkers/Crutches Standerd Rolling Walker(E0143) Crutches(E0114) Rolling Walker w/seat attach E0143+E0156 Knee Walker (E0118) Bedside Commodes Standerd Beside Commode(E0163) Other Equipment Not Specified:Face to Face DocumentationDate Date Format: MM slash DD slash YYYY Ordering Physician First NPI First
