Hospital Bed Order Form

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Prescriber Name A value is required. Phone Number A value is required.Invalid format.
Address A value is required. NPI A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
City A value is required. Fax

Patient Name: A value is required. Phone Number: A value is required.Invalid format.
Address: Weight A value is required.Minimum number of characters not met.Exceeded maximum number of characters.(lbs)
City: Height (ft' in")
Zip: Date Of Birth A value is required.Invalid format.

Emergency Contact:

Phone Number:

Length of Need:

(Months)

Lifetime

Payment Method

Primary Insurance

ID#

Secondary Insurance

ID#:

Does Patient have a Medicare Advantage Plan?

Primary Diagnosis Supporting Need of Wheelchair

Additional Information:
1. Does the patient have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed?
2. Does the patient require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain?

3. Does the patient require the head of the bed to be elevated more than 30 degrees most of the time due to a congestive heart failure, chronic pulmonary disease, or problems with aspiration?

3a. If so have pillows or wedges been considered and ruled out?

4. Does the patient require traction equipment which can only be attached to a hospital bed?
5. Does the patient require a bed height different than that of a fixed height hospital bed to permit transfers to chair, wheelchair or standing position?

6. Does the patient require frequent or immediate changes in body position?