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Patient Referral
Lymphedema Treatment Act
Education
ICD-10 Codes
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Referring Agency
Referral Phone or Email
Patient Name
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Male
Female
Patient Address
City, State, Zip Code
Patient Phone Number
*
Patient Date of Birth
Insurance ID
Insurance Company
Prescribing Physician
*
License/NPI
Doctor Address
Physician Phone Number
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Physician Fax Number
COMPRESSION WRAPS
LOWER EXTREMITY
Affected Limb:
Left
Right
Bilateral
Compression
15-20 mmHg
20-30 mmHg
30-40mmHg
40-50mmHg
Body Part
Foot
Calf
Knee
Thigh
Full Leg
Waist
UPPER EXTREMITY
Affected Limb
Left
Right
Bilateral
Compression
15-20 mmHg
20-30 mmHg
30-40mmHg
40-50mmHg
Body Part
Hand
Arm Sleeve
Head and Neck
Vest
Diagnosis
Lymphedema I189.0
Other-Please describe below
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