Fern Medical Supplies

Compression Garment Order Form/SWO

Clinical documentation recommendations must match order form

*Upload all manufacturer custom compression garment measurement forms at the bottom of this page*

Date of Order *

Patient Full Name *

Patient Date of Birth *

Patient Phone Number # *

Patient Email Address *

Address

Patient Street Address *

City

State

Country

Postal code

Primary Insurance Payor *

Primary Insurance Member ID *

Secondary Insurance Payor

Secondary Insurance Member ID

Involved Side *

Left

Right

Bilateral

Involved Extremity *

Arm

Leg

Duration of Need *

Lifetime

If other duration of need, please specify:

ICD 10 Diagnosis *

Q82.0 Primary Lymphedema (including Praecox, Milroy's Disease, Tarda

I89.0 Lymphedema, not otherwise classified

I97.2 Secondary Lymphedema - Post Mastectomy

I97.89 Other post-procedural complications and disorders of the circulatory system

Other

If other, please specify (including ICD-10):

Upper Extremity

RTW Daytime Garments

Custom Daytime Garments

Preferred Brand

No Preference

Jobst

Juzo

Medi

RTW Nighttime Garments

RTW Nighttime Garment Quantity

QTY 1

QTY 2

QTY 3

QTY 4

Custom Nighttime Garments

Custom Nighttime Quantity

QTY 1

QTY 2

QTY 3

QTY 4

Velcro Wraps

Velcro Wrap Quantity

QTY 1

QTY 2

QTY 3

QTY 4

Arm Bandaging Kit/QTY

Lower Extremity

REMINDER: QTY is PER PIECE

A Pair = QTY 2

RTW Daytime Garments

Custom Daytime Garments

RTW Nighttime Garments

RTW Nighttime Garments Quantity

QTY 1

QTY 2

QTY 3

QTY 4

Custom Nighttime Garments

Velcro Wraps RTW vs Reduction

Leg Bandaging Kit/QTY

Referring Provider Name *

Referring Provider NPI *

Referring Provider Fax Number # (MD, PA, NP, etc.) *

Submitter Name *

Submitter Email *

Upload Manufacturer Custom Garment Measurement Form Here

Upload Clinical Documentation/Notes Here *

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