Spaces must be filled in and correct choices marked (circled on paper form or checked on emailable form). This information is required by Medicare and other insurance companies.
Customized Dressing Order
Style, drainage and units/month are given for your information only and are determined by Medicare. Our office will send the correct dressing size based on the wound measurements given. Drainage and units/month guidelines indicate which products you may combine based on drainage and how often the dressing needs to be changed.
Place check marks going down the product list beside the dressings desired for each numbered wound site.
WCR must have the patient's signature as well as the physician's name, signature and NPI number in order to bill insurance. WCR will obtain doctor and patient signatures for orders emailed to us from this site.
Confirmation and Tracking for Every Order Superior Customer Care