Ocular Prosthetics, Inc
Physician Order
Prosthetic Eye Services
From To
Doctor: ___________________________________ Stephen E. Haddad, B.C.O.
Ocular Prosthetics, Inc.
NPI: __________________________ 321 N. Larchmont Blvd., Suite 711
Los Angeles, CA 90004
Address: ___________________________________ T: 323.462.6004 F: 323.462.4939
___________________________________
Date: ____________________
For
Patient: ___________________________________ DOB: ____________________
Procedure Order Diagnosis ICD10 Codes
____OS ____ OD ____OU ____ Z90.01 Acquired absence of eye
____ V2623 Custom Ocular Prosthesis ____ Z97.0 Presence of prosthetic eye
____ V2624 Polishing Ocular Prosthesis ____ Q11.1 Anophthalmos
____ V2625 Enlargement of Ocular Prosthesis ____ Q11.2 Microphthalmos
____ V2626 Reduction of Ocular Prosthesis ____ H44.529 Atrophy of globe, unspecified
____ V2627 Scleral Cover Shell Prosthesis ____ Other Diagnosis _______________
____ V2628 Fabrication Ocular Conformer
Length of Need
Ocular Prosthesis X Lifetime
Polishing ____ Every six months ____ Yearly
Physician Signature: _______________________________ Date: ____________________
PLEASE RETURN THE SIGNED AND DATED ORDER TO OUR BUSINESS OFFICE
AND MAINTAIN A COPY IN THE PATIENTS MEDICAL FILE.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- icd 10 cm tabular list of diseases and injuries 2017
- national prosthetics patient database nppd user
- ocular prosthetics inc
- prosthetics basics user manual veterans affairs
- cumulative official who updates to icd 10 1996 2001
- appendix c to part 4 veterans affairs
- american society of echocardiography organization of
Related searches
- ocular antibiotic drops
- list of ocular medications
- ocular plastic surgeons dallas tx
- ocular migraines
- ocular migraine stroke symptoms
- frequent ocular migraines without headache
- ocular migraine without headache
- what causes ocular migraines
- frequent ocular migraines
- ocular migraine symptoms
- are frequent ocular migraines dangerous
- increased frequency of ocular migraines