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Phone: (516-882-7473)

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PRESCRIPTION FORM FOR DOWNLOAD

Scan and Email the PDF document to grovermedllc@gmail.com , ravigrover@grovermed.com
Or Fax @ 516-530-9478

Download Brochure

PRESCRIPTION FORM FOR ONLINE SUBMISSION

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

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

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Who We Are

We are in Hicksville, New York. We are Family Owned and Operated Company, serving the NY area with high quality Medical Equipment and Supplies with free and fast Shipping. Our Clients are our priority.

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Contact Us

100 Newbridge Rd, Hicksville, NY, USA
516-882-7473
516-530-9478
ravigrover@
grovermed.com

rameshthakur@

grovermed.com