Costa Medical™
NPI 1225379308
32 Nassau
Street, Suite 300
ta Medical,
LLC
www.Costamedical.org
Toll Free: 855-90Costa
Princeton, NJ 08542
Suzanne@costamedical.org
609-558-4254/ 609-921-8651 (fax)
Ostomy/Wound Care Supply Prescription
Patient's Name:
DOB
Doctor's Name:
Phone:
Today’s Date:
Fax:
Diagnosis CODE (circle all that apply):
Colostomy status V44.3
Ileostomy status V44.2
Artificial opening of urinary track status V44.6
Description of Surface (circle all that apply):
Flat
Uneven
Bell curve
Folds
Other: _________________________
Condition of the skin surface surrounding the stoma/tube(circle all that apply):
Open partial thickness wounds with minimal exudate
Skin Intact?
Yes
No
Closed wound
Open partial thickness without exudate
Redness
Swelling
Blisters
Location of Wound (circle all that apply):
Proximate to stoma
Abdomen
Pelvis
Hip
Proximate to incision
MEDICAL PRODUCT
TRANSPARENT DRESSING, POLYURATHANE DRESSING STERILE OR NON-STERILE
NAME OF PRODUCT (CIRCLE PRODUCT)
# PACKS PER MONTH FOR NEXT 90 DAYS
AQUA
SEAL Size of Product: 6” OD 1/2” ID 10per pk
1
2
3
STOMA
SEAL Size of Product: 4.75 OD 1” ID 10per pk
1
2
3
HCPC
A5126
A5126
NOTE ONLY 2 PACKS (20 UNITS ALLOWABLE BY MEDICARE)
Number of dressings to be used at each dressing change (if more than one):
Frequency of Dressing Changes: ONCE A DAY
Expected duration of need if longer than 3 months?
CHANGE AS NEEDED
YES [ ]
NO [ ]
None
OTHER__________________
NOT SURE* [ ]
Please Circle and / or fill in the following information if you would like it followed.
1. Measure if any wound appears, or you have changes in current wound, note any change in depth and color and or smell
to doctor or WOCN
2. Apply as directed
3. Monitor for signs and symptoms of infection
Doctor's signature:
*If patient requires reassessment
NPI#:
Date: