Pediatric Equipment Referral Form PhoneThis field is for validation purposes and should be left unchanged.Section 1 – Referring ProviderProvider Name(Required)Practice Name(Required)NPI Number(Required)Phone Number(Required)Fax Number(Required)Email Address Section 2 – Patient InformationChild Name(Required)Date of Birth(Required) MM slash DD slash YYYY Parent/Guardian Name(Required)Parent/Guardian Phone(Required)Insurance Name(Required)AddressMember IDSection 3 – Diagnosis InformationPrimary ICD-10 Diagnosis(Required)Secondary ICD-10 DiagnosisSection 4 – Equipment RequestedMobility(Required) Pediatric Walker Pediatric Wheelchair Adaptive Stroller Gait Trainer Respiratory(Required) Pediatric Nebulizer Compressor Supplies Bath Safety(Required) Pediatric Bath Chair Transfer Equipment Positioning(Required) Positioning Device Specialty Mattress Other Equipment Other Equipment OtherSection 5 – Length Of NeedLength Of Need 3 Months 6 Months 12 Months Lifetime (99 Months) Section 6 – Medical NecessityMedical Necessity(Required)Section 7 – Document UploadsClinical Notes(Required)Max. file size: 1 GB. PT EvaluationMax. file size: 1 GB. OT EvaluationMax. file size: 1 GB. Insurance InformationMax. file size: 1 GB. Additional DocumentationMax. file size: 1 GB. Section 8 – Provider CertificationConsent(Required) I certify that I have evaluated this patient and the requested pediatric equipment is medically necessary.Electronic Signature(Required)Date Signed(Required) MM slash DD slash YYYY
