PROVIDER NAME AND ADDRESSHEALTHNETPROVIDER IDENTIFIER2A PROVIDER TAXON - PDF document

1 PROVIDER NAME AND ADDRESSHEALTHNETPROVID
PROVIDER NAME AND ADDRESSHEALTHNETPROVIDER IDENTIFIER2A. PROVIDER TAXONOMYCODE 3.RESPIRATORYSS CERTIFYTHATI HAVE PROVIDED THE SERVICES REPORTED ON THIS FORM:PROVIDER SIGNATUREDATEATTENDING PHYSICIAN SIGNATURE*(REQUIRED IN ALLCASES)DATEOTHER THAN ATTENDING PHYSICIANÕS SIGNATURE** MISSOURI DEPARTMENTOF SOCIALSERVICESMO HEALTHNETDIVISIONISSOURI MEDICAIDMEDICAIDEQUIPMENTPROGRAM OXYGEN AND RESPIRATORYEQUIPMENT MEDICALJUSTIFICATION 6-086-08 .PATIENT INFORMATION FROM MO HEALTHNETI.D. CARDS) B.ATTENDING PHYSICIAN INFORMATION (B AND C MUSTBE COMPLETED BYATTENDING PHYSICIAN ONLY) .MEDICALDOCUMENTATIOND.RESULTS OF TESTING (D AND E MUSTBE COMPLETED BYATTENDING PHYSICIAN OR LABORATORY) E.PRESCRIPTION (PLEASE CHECK APPROPRIATE SPACE) PROVIDER INFORMATION 1.PATIENTÕS NAME AND ADDRESS2.MO HEALTHNETIDENTIFICATION NUMBER3.DATE OF BIRTH1.DIAGNOSIS2.PROGNOSIS3.DATE PATIENTLASTEXAMINED BYYOU ) ATREST12 HOURSDATE OF RXLPM DURING EXERCISE24 HOURSFROMTHRULPM CONTINUOUSLYOTHERNEW RXYESNOATNOCRECERTIFICATIONYESNOLIQUIDTANKCONCENTRATORDURATION OF NEED:WEEKSMONTHSLIFETIME SIGNATURE CERTIFIES ATTESTATION OF PRESCRIPTION AND MEDICALTESTING EVIDENCE PROVIDED ON THIS FORMOF THE MEDICALNECESSITYFOR THE PRESCRIBED EQUIPMENTAND/OR TREATMENT, AND CANDOCUMENTED BYTHE PATIENTÕS MEDICALRECORDS.