PRESCRIPTION FORM FOR DOWNLOAD Scan and Email the PDF document to grovermedllc@gmail.com , ravigrover@grovermed.comOr Fax @ 516-530-9478 Download Brochure PRESCRIPTION FORM FOR ONLINE SUBMISSION Prescription Form Prescription Form Patient's Name Patient Sex Female Male Patient's DOB Date of Injury Patient's Phone and Email Insurance Name and Address Policy # DIAGNOSIS(ICD.10) Patient's Address Country USA Item Description: Back Brace, Lumbar Sacral Orthosis (LSO): Back Lumbar Orthosis, sagittal control, with rigid anterior and posterior panels LSO , sagittal control with rigid anterior and posterior panels LSO , sagittal-coronal control with rigid anterior and posterior farme/panels LSO , sagittal control with rigid anterior and posterior panels LSO , sagittal-coronal control with rigid anterior and posterior panels Back Brace, Thoracic Lumbar Sacral Orthosis (TLSO): Aspen TLSO, flexible, provides trunk support thoracic region. rigid posterior panel and soft anterior apron TLSO, flexible, provides trunk support thoracic region. rigid posterior panel and soft anterior apron Shoulder Brace, Shoulder Orthosis (SO): SO, Abduction Restraine, Prefab, Off -the-Shelf SO, Acromio/Clavicular, Prefab, Off -the-Shelf Wrist Brace: Wrist Hand Finger Orthotic (WHFO) WHO, Cock-up, prefabricated, OTS Knee Brace | Knee Orthosis (KO): KO, locking knee joint(s) KO, adjustable knee joint(s) KO, adjustable knee joints, ROM KO, double upright, Thigh and Calf, with Adjustable Flexion and Extension joint After injection: L1832 or L1833 Post Op 6-8 weeks, functional: L1845 Ankle Brace | Ankle Foot Orthotic (AFO): AFO,Off-the-shelf, night sprint AFO, with ankle joint Cervical Collar: Cervical Collar, Semi-Rigid Thermoplastic Foam Two piece prefabricated, Off-the-shelf Miami Cervical Collar; immobilizer for C-Spine and Neck injuries Miami J Collar Brace with extension for Cervical and High Thoracic injuries Ritchie Brace | Custom: Solid Ankle AFO AFO, Plastic w/Ankle Joint Custom Fabricated Addition to Lower Extremity Orthosis, Soft Addition, Varus/Valgus Correction, Plastic Modification, Padded/Lined Others: SAM SPORT PRO 2.0 The CIRCUL 8 WHEELCHAIR WALKER SQUID ACTIVE COLD COMPRESSION NATROX OXYGEN WOUND THERAPY Physician Name and NPI Physician Signature Date of Signature Send Prescription Δ ×
