PATIENT:
SUPPLIER:
NAME: ____________________________________________________
ADDRESS: __________________________________________________________
CITY
______________________ STATE
PHONE:
_______________________
_______
ZIP ____________
ID#: __________________________
DOB:
SEX:
HEIGHT:
Osteoarthritis
Ligament
WEIGHT:
Patellofemoral
Indications:


Diagnosis:

714.0 rheumatoid arthritis
Recent injury or trauma
Surgical procedure on the knee(s)
Date_________



Thruster RLF
CPM

20/50


SPINE

PAIN RELIEF
AFO’S
Custom Knee Evaluation L9900






715.16 osteoarthritis
717.0 meniscal cartilage derangement
717.81 Knee ligamentous disruption
836.0 dislocation of knee
844.0-844.2 sprains and strains of knee
996.4-996.49 Failed total knee arthroplasty

Other:____________________________
Provide off the shelf brace as indicated
Z12
Shoulder E0936

CPM Pad Kit E0185

Delivery & Set up
A9901
Knee E0935

CPM Pad Kit E0185

Delivery & Set up
A9901

Chair Back LSO L0637

Standard LSO L0631

Cervical Traction E 0849
Indications:

Restore ROM

Decrease pain, stiffness

Decrease edema, inflammation

Decrease muscle spasms.

Other_________________________
Length of need
Weeks__2___4__6__8 ___Medicare 21 days
Diagnosis:







996.4-996.49 Failed total knee arthroplasty
844.0-844.2 sprains and strains of knee
Total Knee replacement
MUA manipulation under anesthesia
Adhesive capsulitis
Other___________
Other___________
Indications








Relieve pain by restricting motion
Facilitate healing Following an injury to spine/soft tissue
Facilitate healing Following Surgery on the Spine/Soft tissue
Support weak Spinal Muscle and /or deformed spine
Provide posterior and lateral support
Restore normal curvature of the spine
Reduce intervetebral Disc pressure
Other
Diagnosis

722.52

724.4

724.2

722.10

Other
Indications:
COLD THERAPY
MOBILITY
NEXT STEP MEDICAL
4501 B N WITCHDUCK ROAD,
VIRGINIA BEACH, VIRGINIA 23455
Phone: 757.802.3210 Fax (757) 802-3210
NPI # 1740597202

Cold therapy unit + Pads

Mobilegs Crutches E0114

Knee Walker Rental E1031






I am prescribing Next Step Medical Cold Therapy for the above patient because the local anesthetic and medicinal value of this modality
reduces pain, edema, ecchymosis and joint effusion. Skin temperatures are to be maintained at a constant, controlled temperature for a
period of _____ days in order to effectively manage pain. Ice or ice substitutes are an uncontrolled source of cold and cannot be used (ice
should NOT be applied continuously due to possible tissue damage). For these reasons ice is not being considered as a prescribed therapy
for this patient. This form of post acute injury therapy, in my opinion, is the absolute best course of action and protocol to follow and
manage this patient’s rehabilitation and ambulation. I believe that the use of controlled cold therapy in this case will reduce or eliminate
pain and edema so that an accurate assessment of the patient’s objective findings can be made. Next Step Medical controlled cold therapy
will limit this patient’s hospital stay and enhance outpatient rehabilitation.
Indications:
WilloMD Purchase L3999
NNMES Unit: IF E0745
TENS Unit: E0730
Conductive Garment E0731
AFO Dynamic
Flex-Foot energy-return
L1932
Custom AFO Evaluation
L9900






Diagnosis:
Indications:








Non weight bearing
Partial weight bearing
Allow affected joint to heal following treatment
Relieve and manage chronic pain
Maintaining or increasing Range of Motion
Other_____________________________
Other
Diagnosis:

Relieve and manage chronic pain
Relax Muscle Spasms
Maintaining or increasing Range of Motion
Prevention and retardation of disuse atrophy
Muscle re-education
Increasing Local blood supply
Other __________________
Indications:
Other
Diagnosis

Drop foot secondary to CVA, MS, Charcot Marie Tooth disease, other
neurological conditions, or mild knee instability

Other______________________________






Post CVA (stroke)
Charcot Marie Tooth Disease
Diabetic Neuropathy
Mild Muscular Dystrophy
Post Spinal Cord Surgery
Other
I certify that I am the treating physician identified above. I certify that the prescribed equipment is medically indicated and, in my opinion, is reasonable and necessary
with reference to the accepted standards of medical practice and treatment of this patient’s condition and is not prescribed as “convenience” equipment.
Signature:
 PLEASE FAX SIGNED ORDER TO 757-802-3210
 PLEASE FAX PATIENT FACE SHEET
 PLEASE FAX MRI/XRAY/CT RESULTS
Date
.
 PLEASE FAX CHART NOTES
 RETAIN THIS ORIGINAL IN PATIENTS MEDICAL RECORD
 CALL NEXT STEP AT 757-802.3210 W/ QUESTIONS