Unit Prescribed Pelvic Floor Stimulator: Pathway STM-10Utah Medical LibertyNonePlease Select 1 Checkbox sEMG Biofeedback: None TR10 TR10c TR20 Please Select 1 Checkbox Does patient need a sensor?Pathway VaginalPathway RectalUM-VaginalUM-RectalOther Other: Does patient need other accessories? Billing?Self PayMedicarePrivate Ins. # of Months Purchase or Rental?PurchaseRental Patient Demographics Information First Name: Last Name: D.O.B. Email: Phone: Street: City: State:Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip: Emergency Contact Name: Phone: Diagnosis & ICD-10 Coding ICD-10 Coding:Please select... N94.89 Pelvic Pain, Female N31.9 Detruser Instability M6240 Muscle Spasm, Unspecified Site N393 Stress Incontinence, Male N393 Stress Incontinence, Female N3946 Mixed Incontinence R159 Fecal Incontinence M6281 Muscle Weakness Other ICD-10 Coding:Please select... N94.89 Pelvic Pain, Female N31.9 Detruser Instability M6240 Muscle Spasm, Unspecified Site N393 Stress Incontinence, Male N393 Stress Incontinence, Female N3946 Mixed Incontinence R159 Fecal Incontinence M6281 Muscle Weakness Other ICD-10 Coding:Please select... N94.89 Pelvic Pain, Female N31.9 Detruser Instability M6240 Muscle Spasm, Unspecified Site N393 Stress Incontinence, Male N393 Stress Incontinence, Female N3946 Mixed Incontinence R159 Fecal Incontinence M6281 Muscle Weakness Other Other ICD-10 Coding Prognosis? Excellent Good Fair Poor Are the pelvic nerves intact?Yes No Documented failed 4 -week trial of Pelvic Muscle Exercises? Yes No Has the patient had an in-office visit with the Ordering Physician within six months prior to the Date of Signature? Yes No Anticipated Benefit From Use: Increase Pelvic Muscle Strength Increase Pelvic Muscle Coordination Decrease Urinary Leakage Increase Voiding Interval Neuromuscular Re- Education Decrease Involuntary Detruser Contractions Other Other Use PFS Prescribed To: Improve Urethral Closure Function Improve Urethral Sphincter Function Inhibit Unwanted Bladder Contractions Other Other PFS Prescribed To: Primary Insurance Ins. Co: Phone: Primary Insured Name: ID #: Group #: Street: City: State:Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip: Secondary Insurance Ins. Co: Phone: Secondary Insured Name: ID #: Group #: Street: City: State:Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip: Prescribing Physician Information Dr.'s Name: NPI #: Phone: Doctor's Fax Number Street: City: State:Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip: Therapist Information Therapist: Facility: Facility ID#: Phone: Email Street: City: State:Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip: Preferred Method of Delivery? Please select 1 optionPlease deliver to clinicians facilityPlease deliver to my patients home.* If ordering a STM-10 or TR-10C, would you like it programmed?YesNo STM-10: Session Time:Please select... 5 min 10 min 15 min 20 min 25 min 30 min Duty Cycle:Please select... 5:5 5:10 10:10 10:20 Cont. Stim Mode:Please select... 12.5 HZ 50 HZ 100 HZ 200 HZ 12/50 HZ TR-10C: Goal:Please select... Above Below Work-Rest 5/10 Work-Rest 10/10 Scale:Please select... 800UV 30UV My above signature indicates my approval of this order and it’s accuracy. *My above signature indicates my approval to ship the instrument to my patient’s home and releases Current Medical Technologies, Inc. from any liability from it’s use prior to proper instrument education and training. Please note, due to state regulations we are not allowed to ship direct to Tennessee. Maryland and Kansas residents. If you have any questions, please contact Current Medical Technologies DME department 800-382-5879 ext. 4. Contact Information
