Page 265 - Edgepark Full Line Catalog 2017

Order Form
Please complete all fields, as inaccurate or incomplete information may delay this order.
Ref. #:
Health Care Professional: ______________________________________________________________________ Facility: _______________________________________________________________________________________ Phone #: ___________________________________________ Fax #: ___________________________________
p 1-800-321-0591 f 1-330-963-6172 w www.edgepark.com
First: _________________________________________ Last: __________________________________________ MI: ______________ DOB: ________________________________ Address: _________________________________________________________________________________________________________ _______________________________________ City: _____________________________________________________________________________________ State: ____________________ ZIP: ________________________________ Phone #: ____________________________________________ E-mail Address: (optional): __________________________________________________________________________
Primary: ________________________________________________________________ Contract/Policy #: ________________________________________________________ Group #: _________________________________________________________________ Phone #: _________________________________________________________________ Policy holder’s name: _____________________________________________________
Secondary: ________________________________________________________________ Contract/Policy #: ___________________________________________________________ Group #: ____________________________________________________________________ Phone #: ____________________________________________________________________ Policy holder’s name: ________________________________________________________
Physician Name: _________________________________________________________ Street Address: __________________________________________________________ City/State/ZIP: ___________________________________________________________ Phone #: _________________________________________________________________ Fax#: ___________________________________________________________________
Diagnosis: _______________________________________________ Type of Ostomy: Colostomy Ileostomy Urostomy
Reason for Ostomy: _________________________________________
Type, if Diabetic:
Insulin-Dependent - Times Testing Per Day: _________________ Non-Insulin Dependent - Times Testing Per Day: _____________ Gestational - Times Testing Per Day: _______________________
Patient chooses to purchase glucose meter? Yes No
Patient chooses to rent glucose meter? Yes No Type, if Other: ________________________
ITEM #
PRODUCT DESCRIPTION
QTY
Please include all insurance information so we may bill your insurance(s) as appropriate. If you are providing insurance information, send no payment now. A customer care specialist will call you if there is a balance due. Ground shipping is FREE. Additional charges may apply for C.O.D. or premium shipping services (Next Day Air, Second Day Air, Next Day Saturday). Please contact your Edgepark Representative for questions regarding shipping.
Method of Payment
If you are not providing insurance information, please complete this Method of Payment information. Please make check or money order payable to Edgepark. If paying by Visa, MasterCard, Discover or Debit Card, please enter either the 13- or 16-digit number (please read card carefully).
Card # ____________________________________________________________________
Signature _________________________________________________________________
NOTES
Supply Quantity: Items ordered will last ________ [days/months] (circle one)
Shipping time of 1 – 2 business days to 99% of the U.S. population, after order processing. Obtaining prescription information and verifying insurance coverage typically takes up to 4 days for rst-time orders, and 3 days for reorders.
Unless otherwise indicated, comparable-quality products may be used to maximize patient’s insurance bene ts (subject to medical necessity and insurance guidelines).
* Medicare Patients
How many days of supplies does the patient have on hand? ________
*Is the patient under any type of care in the home or any other facility (Home Health Care/Skilled Nursing Facility/Hospital)?
Yes No
If “yes,” please fill out the following:
Facility Name:____________________ Facility Phone #:______________ Start of Care Date: _____________ Discharge Date: ________________
Has anyone come to the patient’s home in the last 60 days to assist in health care? Yes No
(as it appears on credit card)
Expiration Date: ___________/___________/___________
Diagnosis
Doctor Insurance Patient Facility