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VascuEase DVT, AOB & WOF Prescription Form

Patient Information



ASSIGNMENT OF BENEFITS / AUTHORIZATION TO RELEASE INFORMATION

I authorize VasoCARE to provide the product(s) and treatment prescribed by my physician, and that I have received the product(s) and such services. I authorize VasoCARE to submit claims to my insurer on my behalf, and I assign the benefits payable by my insurer for such product(s) to VasoCARE. I authorize my physician and VasoCARE to release any of my medical . information required for my insurer to process the claim.

Physician Letter of Medical Necessity / Physician Written Order / Prescription


VascuEase Portable DVT System Device

DVT Device Exclusion Triggers:

Automatic VeinOPlus DVT Device Triggers:

THROMBOSIS RISK ASSESSMENT


One Point Each:

Two Points Each:

Five Points Each:

Three Points Each:

Total Risk Points:
Low Risk: 0-1 point
Moderate Risk: 2 points
High Risk: 3-4 points
Very High Risk: 5+ points

I have assessed this patient’s risk of DVT based on the type of surgery, the patient’s medical history and other documented factors that may increase the risk of DVT. My assessment indicated the use of mechanical thromboprophylaxis by intermittent pneumatic compression. In my opinion, this is medicall necessary and reason able in accordance with accepted standards of medical practice and appropriate treatment of this patient.

Please fax signed and dated PWO, Medical Records, and Face Sheet to:
VasoCARE @ 1-866-455-5150

P.O. Box 14933 l Baton Rouge, LA 70898
PHONE: 800-256-9979 FAX: 866-455-5150

© 2019-Present by VasoCARE, LLC. All rights reserved by VasoCARE. Visit us at vasocare.com

For best results, in your print dialog, check “Shrink to Fit Page” if available, and turn off page headers and footers.
If you have issues printing this form, please download and use the PDF version.