Patient Instructions for Home Medical Equipment

Transcription

1 Patient Instructins fr Hme Medical Equipment In rder fr ABC Health Care t cmplete the request fr yur prescribed hme medical equipment, we will need the fllwing dcumentatin requirements cmpleted in full and prvided t ur ffice in their entirety. 1. Receive cpy f ABC Health Care Hme Medical Equipment Instructins & Dcumentatin Requirements packet Cmpleted 2. Fill ut the ABC Health Care Patient Infrmatin Recrd dcument Cmpleted Patient Name: ABC Patient ID #: 3. Using the Written Order Requirements dcument, cnfirm yur prescriptin / written rder written by yur physician meets the insurance-driven requirements. If nt, cntact yur prescribing physician fr a new prescriptin / "written rder" r t make the apprpriate changes t yur existing prescriptin Imprtant, please nte - All edits t an existing prescriptin must be initialed and dated by the signing physician. Cmpleted 4. Using the Equipment Dcumentatin Requirements dcument, cnfirm all Insurance-required dcumentatin is included. If nt, cntact yur physician t request the Insurance-required medical dcumentatin. IMPORTANT - Medical dcumentatin written n a prescriptin / "written rder" is nt accepted by Insurance cmpanies. It must be written separately in yur medical recrds and be part f yur medical histry frm yur prescribing physician. Cmpleted 5. Once cmplete, submit all f the fllwing t ABC s DME department. It will be scanned and returned t yu. "Patient Instructin fr Hme Medical Equipment" frm "ABC Health Care Patient Infrmatin Recrd" frm Valid Prescriptin / Written Order Equipment Dcumentatin frm with the accmpanying Medical Recrds / Medical Dcumentatin 6. An ABC Health Care Medicare Quality Assurance assciate will review the rder and dcumentatin within 48 hurs f submissin. If rder and dcumentatin are nt cmplete, the Medicare Quality Assurance assciate will deny the request fr equipment and infrm yu f reasns. If rder and dcumentatin are cmplete, the Medicare Quality Assurance assciate will apprve the request fr equipment and infrm yu f apprval and prcess fr receiving yur equipment. Imprtant, please nte ABC will nly prvide equipment after patient c-payment, deductible, and/r prir balance is cllected. 7. ABC Health Care will file yur medical equipment claim with Medicare fr yu and an Explanatin f Benefits frm CMS will fllw t cnfirm billing is cmplete. ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Versin Dated 5/1/2017

2 Patient Infrmatin Recrd Date: Patient Infrmatin: Last Name: First Name: MI: Date f Birth: SS#: Hme Address: City: State: Zip: Cell phne: Wrk phne: Hme phne: Caregiver / Respnsible Party Infrmatin: Last Name: First Name: MI: Cell phne: Wrk phne: Hme phne: Clinical Infrmatin: Gender: Male Female Height: Weight: Health / Infectin Risk: Yes N If Yes, prvide detail: Primary Care Physician: PCP Address: City: State: Zip: Health Insurance Infrmatin: Primary Insurance Cmpany: Plicy Number: Grup Number: Subscriber Name: Relatinship t Subscriber: Self Spuse Child Other: Secndary Insurance Cmapny: Plicy Number: Grup Number: Subscriber Name: Relatinship t Subscriber: Self Spuse Child Other: Tertiary Insurance Cmpany: Plicy Number: Grup Number: Subscriber Name: Relatinship t Subscriber: Self Spuse Child Other: ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Versin Dated 7/1/2016

3 Written Order Requirements Example Hspital Bed Per Medicare and the Affrdable Care Act, a detailed written rder fr DME items must be (A) received befre the delivery f an item can take place and (B) must include the fllwing infrmatin (as shwn in the example belw): 1. Beneficiary's name 2. Physician's name 3. Physician s NPI 4. Date f the rder 5. Detailed descriptin f the item(s) with additinal details, as applicable: a. Detailed descriptin f item(s) t be dispensed (with HCPC cdes, if pssible) b. Quantity t be dispensed c. Frequency f use d. Duratin / Length f need e. Number f refills f. Rute f administratin (primarily nly fr respiratry items) g. Dsage & cncentratin (primarily nly fr respiratry items) 6. Physician signature 7. Physician signature date James S. De, M.D Market Street, Hamptn, VA Phne: (757) Rbert Jnes 1411 Green Place, Chesapeake, VA NPI# /01/ /19/1945 Name: 1 Date: 4 Address: DOB: 3 a 5 E0260 Semi-electric hspital bed with E0910 Trapeze Bar and E0274 ver-bed table mnths 1 Refills: e Quantity: b Length f Need: d James S De 07/01/ Signature f Prescriber: Signature Date: 7 ***IMPORTANT Any / each change made t prescriptin that is already signed, must be initialed and dated by the physician t be accepted by Medicare*** ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Versin Dated 7/1/2016

4 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Equipment Requirements & Check-Off List Hspital Beds In rder fr ABC Health Care t cmplete the request fr yur prescribed hme medical equipment, we will need the fllwing dcumentatin requirements cmpleted in full and prvided t ur ffice in their entirety. Fixed Height Hspital Bed Head and ft f bed are adjustable with manual hand-crank Bed frame, legs, & mattress height are fixed; height is nt adjustable Includes Bed Rails and standard Dry Mattress Detailed Written Order Requirements: Patient name Date f rder Detailed descriptin = E0250 Fixed height bed Quantity = 1 Frequency = Daily Duratin / length f need = 99 mnths Physician name Physician signature Physician signature date NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: In rder t qualify fr any hspital bed, the fllwing statement and at least ONE f the cnditins (listed belw) must be included t validate Medicare s requirements: (specify diagnsis and assciated symptms) makes patient physically incapable f utilizing an rdinary bed because: The patient requires psitining f the bdy in ways nt feasible with an rdinary bed including head/upper bdy psitining greater than 30 degrees. The patient requires psitining f the bdy in ways nt feasible with an rdinary bed in rder t alleviate pain. The patient requires the head f the bed t be elevated mre than 30 degrees mst f the time due t cngestive heart failure, chrnic pulmnary disease, r prblems with aspiratin. The patient requires tractin equipment, which can nly be attached t a hspital bed. Withut the use f the hspital bed, patient will nt be able t manage disease and symptms sufficiently and it will impair ne r mre mbility-related activities f daily living in the hme. Patient s mbility & daily living deficit can be sufficiently imprved by use f hspital bed. Patient is willing and able t safely use the hspital bed in the hme. Imprtant: Any supplied dcumentatin stating the patient s head/upper bdy des nt need elevatin greater than 30 degrees will disqualify patient fr a hspital bed. ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 1 Versin Dated 7/1/2016

5 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Variable Height Hspital Bed Head and ft f bed are adjustable with manual hand-crank Bed frame, legs, & mattress height are adjustable with manual hand-crank Includes Bed Rails and standard Dry Mattress Detailed Written Order Requirements: Patient name Date f rder Detailed descriptin = E0255 Variable height bed Quantity = 1 Frequency = Daily Duratin / length f need = 99 mnths Physician name Physician signature Physician signature date NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: In rder t qualify fr any hspital bed, the fllwing statement and at least ONE f the cnditins (listed belw) must be included t validate Medicare s requirements: (specify diagnsis and assciated symptms) makes patient physically incapable f utilizing an rdinary bed because: The patient requires psitining f the bdy in ways nt feasible with an rdinary bed including head/upper bdy psitining greater than 30 degrees. The patient requires psitining f the bdy in ways nt feasible with an rdinary bed in rder t alleviate pain. The patient requires the head f the bed t be elevated mre than 30 degrees mst f the time due t cngestive heart failure, chrnic pulmnary disease, r prblems with aspiratin. The patient requires tractin equipment, which can nly be attached t a hspital bed. Patient requires a bed height different than a fixed height hspital bed t permit transfers t chair, wheelchair r standing psitin. Withut the use f the hspital bed, patient will nt be able t manage disease and symptms sufficiently and it will impair ne r mre mbility-related activities f daily living in the hme. Patient s mbility & daily living deficit can be sufficiently imprved by use f hspital bed. Patient is willing and able t safely use the hspital bed in the hme. Imprtant: Any supplied dcumentatin stating the patient s head/upper bdy des nt need elevatin greater than 30 degrees will disqualify patient fr a hspital bed. *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 2 Versin Dated 7/1/2016

6 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Semi-Electric Hspital Bed Head and ft f bed are adjustable with electric mtr & hand remte Bed frame, legs, & mattress height are adjustable with manual hand-crank Includes Bed Rails and standard Dry Mattress Detailed Written Order Requirements: Patient name Date f rder Detailed descriptin = E0260 Semi-electric bed Quantity = 1 Frequency = Daily Duratin / length f need = 99 mnths Physician name Physician signature Physician signature date NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: In rder t qualify fr any hspital bed, the fllwing statement and at least ONE f the cnditins (listed belw) must be included t validate Medicare s requirements: (specify diagnsis and assciated symptms) makes patient physically incapable f utilizing an rdinary bed because: The patient requires psitining f the bdy in ways nt feasible with an rdinary bed including head/upper bdy psitining greater than 30 degrees. The patient requires psitining f the bdy in ways nt feasible with an rdinary bed in rder t alleviate pain. The patient requires the head f the bed t be elevated mre than 30 degrees mst f the time due t cngestive heart failure, chrnic pulmnary disease, r prblems with aspiratin. The patient requires tractin equipment, which can nly be attached t a hspital bed. T qualify fr semi-electric bed, at least ONE f the fllwing cnditins must be included: Patient requires frequent changes in bdy psitin. Patient has an immediate need fr a change in bdy psitin. Withut the use f the hspital bed, patient will nt be able t manage disease and symptms sufficiently and it will impair ne r mre mbility-related activities f daily living in the hme. Patient s mbility & daily living deficit can be sufficiently imprved by use f hspital bed. Patient is willing and able t safely use the hspital bed in the hme. Imprtant: Any supplied dcumentatin stating the patient s head/upper bdy des nt need elevatin greater than 30 degrees will disqualify patient fr a hspital bed. *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 3 Versin Dated 7/1/2016

7 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Heavy Duty Hspital Bed Head and ft f bed are adjustable with electric mtr & hand remte Bed frame, legs, & mattress height are adjustable with electric mtr & hand remte Includes Bed Rails and standard Dry Mattress Detailed Written Order Requirements: Patient name Date f rder Detailed descriptin = E0301 Heavy Duty bed Quantity = 1 Frequency = Daily Duratin / length f need = 99 mnths Physician name Physician signature Physician signature date NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: In rder t qualify fr any hspital bed, the fllwing statement and at least ONE f the cnditins (listed belw) must be included t validate Medicare s requirements: (specify diagnsis and assciated symptms) makes patient physically incapable f utilizing an rdinary bed because: The patient requires psitining f the bdy in ways nt feasible with an rdinary bed including head/upper bdy psitining greater than 30 degrees. The patient requires psitining f the bdy in ways nt feasible with an rdinary bed in rder t alleviate pain. The patient requires the head f the bed t be elevated mre than 30 degrees mst f the time due t cngestive heart failure, chrnic pulmnary disease, r prblems with aspiratin. The patient requires tractin equipment, which can nly be attached t a hspital bed. Patient weight was (enter weight; must be ver 350 lbs) punds n (specify date; must be within ne mnth f receipt f bed). Withut the use f the hspital bed, patient will nt be able t manage disease and symptms sufficiently and it will impair ne r mre mbility-related activities f daily living in the hme. Patient s mbility & daily living deficit can be sufficiently imprved by use f hspital bed. Patient is willing and able t safely use the hspital bed in the hme. Imprtant: Any supplied dcumentatin stating the patient s head/upper bdy des nt need elevatin greater than 30 degrees will disqualify patient fr a hspital bed. *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 4 Versin Dated 7/1/2016

8 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Extra Heavy Duty Hspital Bed Head and ft f bed are adjustable with electric mtr & hand remte Bed frame, legs, & mattress height are adjustable with electric mtr & hand remte Includes Bed Rails and standard Dry Mattress Detailed Written Order Requirements: Patient name Date f rder Detailed descriptin = E0302 Extra heavy duty bed Quantity = 1 Frequency = Daily Duratin / length f need = 99 mnths Physician name Physician signature Physician signature date NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: In rder t qualify fr any hspital bed, the fllwing statement and at least ONE f the cnditins (listed belw) must be included t validate Medicare s requirements: (specify diagnsis and assciated symptms) makes patient physically incapable f utilizing an rdinary bed because: The patient requires psitining f the bdy in ways nt feasible with an rdinary bed including head/upper bdy psitining greater than 30 degrees. The patient requires psitining f the bdy in ways nt feasible with an rdinary bed in rder t alleviate pain. The patient requires the head f the bed t be elevated mre than 30 degrees mst f the time due t cngestive heart failure, chrnic pulmnary disease, r prblems with aspiratin. The patient requires tractin equipment, which can nly be attached t a hspital bed. Patient weight was (enter weight; must be ver 600 lbs) punds n (specify date; must be within ne mnth f receipt f bed). Withut the use f the hspital bed, patient will nt be able t manage disease and symptms sufficiently and it will impair ne r mre mbility-related activities f daily living in the hme. Patient s mbility & daily living deficit can be sufficiently imprved by use f hspital bed. Patient is willing and able t safely use the hspital bed in the hme. Imprtant: Any supplied dcumentatin stating the patient s head/upper bdy des nt need elevatin greater than 30 degrees will disqualify patient fr a hspital bed. *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 5 Versin Dated 7/1/2016

9 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Ttal Electric Hspital Bed Head and ft f bed are adjustable with electric mtr & hand remte Bed frame, legs, & mattress height are adjustable with electric mtr & hand remte Includes Bed Rails and standard Dry Mattress ***IMPORTANT*** Medicare will nt pay fr a Ttal Electric bed. Ttal Electric is deemed a cnvenience feature that is nt reasnable and necessary. In rder t receive a Ttal Electric bed, the patient will need t meet the qualificatins fr a Semi- Electric bed and privately pay the difference in reimbursement between Semi-Electric and Ttal Electric beds. ABC will then bill the Medicare fr the Semi-Electric mdel and cllect the balance frm the patient. Detailed Written Order Requirements: Patient name Date f rder Detailed descriptin = E0265 Ttal electric bed Quantity = 1 Frequency = Daily Duratin / length f need = 99 mnths Physician name Physician signature Physician signature date NPI n prescriptin that matches rdering physician's signature Dcumentatin within the medical chart frm physician detailing: In rder t qualify fr any hspital bed, the fllwing statement and at least ONE f the cnditins (listed belw) must be included t validate Medicare s requirements: (specify diagnsis and assciated symptms) makes patient physically incapable f utilizing an rdinary bed because: The patient requires psitining f the bdy in ways nt feasible with an rdinary bed including head/upper bdy psitining greater than 30 degrees. The patient requires psitining f the bdy in ways nt feasible with an rdinary bed in rder t alleviate pain. The patient requires the head f the bed t be elevated mre than 30 degrees mst f the time due t cngestive heart failure, chrnic pulmnary disease, r prblems with aspiratin. The patient requires tractin equipment, which can nly be attached t a hspital bed. T qualify fr ttal electric bed, at least ONE f the fllwing cnditins must be included: Patient requires frequent changes in bdy psitin. Patient has an immediate need fr a change in bdy psitin. Withut the use f the hspital bed, patient will nt be able t manage disease and symptms sufficiently and it will impair ne r mre mbility-related activities f daily living in the hme. Patient s mbility & daily living deficit can be sufficiently imprved by use f hspital bed. Patient is willing and able t safely use the hspital bed in the hme. Imprtant: Any supplied dcumentatin stating the patient s head/upper bdy des nt need elevatin greater than 30 degrees will disqualify patient fr a hspital bed. *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 6 Versin Dated 7/1/2016

10 *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Hspital Bed Accessries fr Frame There are a wide variety f accessries available t imprve a patient s experience and safety while in their hspital bed. Belw are sme f the ptins nt shwn in the earlier sectins. T rder, replace r include the cde and item name in the Detailed Descriptin sectin f the Detailed Written Order and prvide the infrmatin in the dcumentatin requirements (these are needed in cnjunctin with the dcumentatin requirements shwn with any hspital bed). E0910 Trapeze Bar Attached t Bed Patient must have at least ne f the fllwing: The patient needs this device t sit up because f a respiratry cnditin. The patient needs this device t sit up t change bdy psitin fr ther medical reasns. The patient needs this device t sit up t get in r ut f bed. E0911 Trapeze Bar Heavy Duty Attached t Bed Patient must have at least ne f the fllwing: The patient needs this device t sit up because f a respiratry cnditin. The patient needs this device t sit up t change bdy psitin fr ther medical reasns. The patient needs this device t sit up t get in r ut f bed. Patient weight was (enter weight; must be ver 250 lbs) punds n (specify date; must be within ne mnth f receipt f bed). E0280 Bed Cradle The patient s cnditin makes it necessary t prevent cntact with the bed cverings. E0274 Over-Bed Table The patient s cnditin requires the use f the ver-bed table t cmplete their daily living needs while in the bed. E0273 Bed Bard The patient s cnditin requires the use f the bed bard t cmplete their daily living needs while in the bed. *This dcument is nt cnsidered Medical Dcumentatin r Medical Evidence. It prvides guidance n what is required within the patient's Medical Recrds.* Mst insurance cmpanies will nt pay fr this item. It must be paid fr privately by the patient r caregiver. ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 7 Versin Dated 7/1/2016

11 Detailed Descriptin Infrmatin Includes HCPC cdes, prduct descriptins fr all bases, attachments, and miscellaneus parts all as defined by Medicare regulatins: Cde Descriptin, as defined by Medicare Additinal criteria E0250 E0251 E0290 E0291 E0328 E0255 E0256 E0292 E0293 E0260 E0261 E0294 E0295 E0329 E0265 E0266 E0296 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT SIDE RAILS, WITH MATTRESS Must meet 1 f the 4 required cnditins Must meet 1 f the 4 required cnditins Must meet 1 f the 4 required cnditins Must meet 1 f the 4 required cnditins Must meet 1 f the 4 required cnditins Must meet minimum cnditins f Fixed Height Bed and different bed height fr transfers Must meet minimum cnditins f Fixed Height Bed and different bed height fr transfers Must meet minimum cnditins f Fixed Height Bed and different bed height fr transfers Must meet minimum cnditins f Fixed Height Bed and different bed height fr transfers Must meet minimum cnditins f Fixed Height Bed and immediate/frequent bdy psitin change Must meet minimum cnditins f Fixed Height Bed and immediate/frequent bdy psitin change Must meet minimum cnditins f Fixed Height Bed and immediate/frequent bdy psitin change Must meet minimum cnditins f Fixed Height Bed and immediate/frequent bdy psitin change Must meet minimum cnditins f Fixed Height Bed and immediate/frequent bdy psitin change Nt cvered by Medicare; must meet cnditins fr Semi-Electric and pay difference Nt cvered by Medicare; must meet cnditins fr Semi-Electric and pay difference Nt cvered by Medicare; must meet cnditins fr Semi-Electric and pay difference ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 8 Versin Dated 7/1/2016

12 E0297 E0301 E0302 E0303 E0304 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS Nt cvered by Medicare; must meet cnditins fr Semi-Electric and pay difference Must meet minimum cnditins f Fixed Height Bed and weigh between lbs Must meet minimum cnditins f Fixed Height Bed and weigh mre than 600 lbs Must meet minimum cnditins f Fixed Height Bed and weigh between lbs Must meet minimum cnditins f Fixed Height Bed and weigh mre than 600 lbs E0271 MATTRESS, INNERSPRING Replacement item nly E0272 MATTRESS, FOAM RUBBER Replacement item nly E0274 E0280 E0305 E0310 E0316 OVER-BED TABLE BED CRADLE, ANY TYPE BED SIDE RAILS, HALF LENGTH BED SIDE RAILS, FULL LENGTH SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE Nn-cvered item by Medicare; cash purchase r rental nly Cvered nly if bed is wned and item is nt currently used with it OR as a replacement part. Cvered nly if bed is wned and item is nt currently used with it OR as a replacement part. Cvered nly if bed is wned and item is nt currently used with it OR as a replacement part. Cvered nly if bed is wned and item is nt currently used with it OR as a replacement part. ABC Health Care 28 Research Drive, Hamptn, VA Phne: (757) Fax: (757) Page 9 Versin Dated 7/1/2016