Medical Order Form
A medical order form is sent by a doctor or a hospital to a vendor for supply of equipments and other medical related products and supplies. This type of form contains details of various medical equipment and supplies, number of units, cost of the equipment and much more. A medical order form is a standard form that can be used by any hospital, medical services, or physicians. A medical order form at times can be sent along with required documentation specific to a product or equipment.
You can Download the Free Medical Order Form, customize it according to your needs and Print. Medical Order Form is either in MS Word, Excel or in PDF.
Sample Medical Order Form
Medical Order Form
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Medical Order Form |
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| Client Name: | Client Date of Birth: | |||||||
| Client Medicaid Number: | Clients Address:
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| Supplier Name: | Supplier Address:
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| Telephone: | Fax: | |||||||
| Supplier TPI: | Supplier NPI: | |||||||
| Supplier Taxonomy: | Supplier Benefit Code: | |||||||
| Physician’s Name: | Phone: | Fax: | ||||||
| I certify that the medical equipments supplied as mentioned in this order are in accordance with the requirements of the physician. The prescribed items are safe and of high quality. These items can be used at the Physician’s clinic, client’s home, or for assisting medical practice elsewhere.
……………………………………. Signature (Medical representative) Date: |
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| Medical Supplies | ||||||||
| S.No | Item description | Qty | Unit Cost ($) | Total Cost ($) | ||||
| 1 | ||||||||
| 2 | ||||||||
| 3 | ||||||||
| 4 | ||||||||
| 5 | ||||||||
| 6 | ||||||||
| 7 | ||||||||
| Sub Total | $ | |||||||
| Taxes | ||||||||
| Total | $ | |||||||
| Additional documentation is required for those medical items that are not authorized for over the counter sale. Authorization should be attached to the Medical Order along with signatures of the authorizing person. | ||||||||
| Each item that has been requested in this form should be accompanied with a medical necessity justification. Please attach the medical necessity justification document along with the order form. | ||||||||
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Signature and attestation of physician |
Date:
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| Physicians License Number: | Payment made through:Cash
Check Credit Card |
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Category: Order Forms
