Prescription Form
for ATOS Medical Provox Heat Moisture-Exchanger>Orders must be from a licensed practitioner trained in the care and rehabilitation of people with laryngectomies and tracheotomies - ie. Physician, Speech Pathologist, Respiratory Therapist
>This form may be copied and used as needed for your patients - or your own prescription form or letterhead may be used, if preferred, as long as it contains the information requested below.
>Standing orders must be renewed yearly. Any changes in specific orders will require a new prescription.
PLEASE PRINT OR WRITE VERY CAREFULLY
Clinician_______________________________________________________________
Address_______________________________________________________________
City___________________________________State_________Zip________________
Licensee#_____________DEA Reg.#______________Medicare UPIN #____________
Phone___________________Fax__________________ e-mail___________________
____ Please send the filled prescription to my patient:
Patient Name___________________________________________________________
Address_______________________________________________________________
City___________________________________State_________Zip________________
Phone___________________Fax__________________ e-mail___________________
_____ You are authorized to supply my patient with ATOS Provox Heat-Moisture Exchange System products, which may include Normal or HiFlow Filter Cassettes, as he/she needs and requests.
(USE THE FOLLOWING SPACE TO GIVE ANY ADDITIONAL ORDERS OR INSTRUCTIONS)
Signature ___________________________________ Date__________________
MAIL OR FAX COMPLETED PRESCRIPTION, WITH FIRST ORDER, TO:
Luminaud, Inc, 8688 Tyler Blvd., Mentor, OH 44060 - Fax: 440-255-2250