Enteral nutrition products prescription form (oral enteral ...



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Enteral Nutrition Products Prescription and Order Form

|Patient’s name |Date of birth |

|      |      |

|Diagnosis |Length of need in months: |

|      |      |

|HCPCS CODE |ITEM NAME |QUANTITY |Kcal/DAY FROM |Kcal/MONTH |HCPCS UNITS PER MONTH |DIRECTIONS FOR USE |

| |and # of Kcal |requested |PRODUCT | | | |

| | |PER DAY | | | | |

|B4160 |PEDIASURE “GROW AND GAIN” 240 |3 CANS |720 Kcal/Day |720 Kcal X 30 DAYS = |216 |1 can with each meal. |

| |Kcal/CAN |per day | |21600 Kcal/Month |per month | |

|      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |

|The prescribing provider and RD are responsible for identifying the NUMBER OF CALORIES being prescribed for the client so HCPCS units can be accurately calculated. Enteral products are reimbursed by HCPCS |

|units. |

|Prescriber’s printed name |Telephone number |Fax number |Prescriber’s NPI |

|      |      |      |      |

|Prescriber’s address |City |State |ZIP code |

|      |      |      |      |

|I certify that I am the prescriber identified above and that the medical necessity information is true, accurate, and complete, to the best of my knowledge. I understand that any falsification, omission, or|

|concealment of material fact in those sections may subject me to civil or criminal liability. (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTED). |

|Prescriber’s signature |Date signed |

| |      |

|PRESCRIBER ATTESTATION - If this is a prescription for a THICKENER for a client under the age of one year: |

|The parent or guardian, the prescribing provider, the child’s PCP, the SLP and the dietitian caring for this child are aware that the Food and Drug Administration (FDA) |

|and the American Academy of Pediatrics (AAP) have warned that Simply Thick and similar products should not be given to infant less than one year old, especially |

|for babies with a history of premature birth due to the risk of necrotizing enterocolitis? Yes No |

Keep in client file. See Billing Guide for information on when this form must be submitted for review..

HCA 13-961 (8/17)

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EXAMPLES

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