VascuEase Prescription Form

Patient Information

First Name:

MI:

Last Name:

Street Address:

City:

State:

Zip:

Hospital / Surgery Center:

Date of Surgery:

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.

Patient’s Signature (print and sign):

Date:

Physician Letter of Medical Necessity / Physician Written Order / Prescription

VascuEase Portable DVT System Device

(E0676) ICD-10 Code(s):

THROMBOSIS RISK ASSESSMENT

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.

Physician Name:

Physician’s Signature (print and sign):

Date: