About Your Ostomy Care Supply Order

Size: px

Start display at page:

Download "About Your Ostomy Care Supply Order"

Rolf Fleming
5 years ago
Views:

1 Patient Education About Your Ostomy Care Supply Order This handout explains how to obtain your supplies for ostomy care. Before you leave the hospital, be sure that your doctor writes your prescription on page 4: Physician Order for Ostomy Supplies. We are here to help you determine the supplies you need so you can successfully care for your ostomy at home. Your doctor or the clinical nurse will teach you how to best care for your ostomy. Your supplies need to be ordered with a doctor s signature like a prescription. The attached prescription form will help you obtain the correct supplies for the care of your ostomy. While your doctor or nurse will help you fill it out, you will need to mail or fax a copy of this document to the medical supply company of your choice; or, if you prefer, you may choose to have your local pharmacy fill the prescription for your supplies. Check the Medical Supplies section of your Yellow Pages and/or see the list we have provided for suggested vendors. This prescription has been personalized for you. Be sure that you keep a copy, and make a photocopy to mail or fax to the vendor or pharmacy. Your medical insurance company and/or DSHS may also require a copy. If you are being discharged to a skilled nursing facility, or if you will be seen at home by home health, they are responsible for providing your supplies until they discharge you from their care. Your insurance will not cover the cost

2 Page 2 of supplies filled by this prescription while you are in a skilled nursing facility or being seen by home health. If the skilled nursing facility or home health agency is unsure of your supply needs, you can show them this list to help them know what supplies to get. When you are discharged from the skilled nursing facility or home health agency, your supply needs may be different and should be re-evaluated at that time. Ostomy Care Supplies On the next page is a list of medical supply companies that sell products for ostomy care. This is a partial list provided for your convenience and does not represent UWMC endorsement. Check with a pharmacy or medical supply store near your home to see if they carry the products you need. Check with your health insurance provider to see if you need to use a particular supply company to obtain coverage for your supplies. You will need a prescription from your doctor to obtain insurance coverage. If you are receiving home health nursing, the supplies will be provided by the home health agency as a part of your care. Notes

Page 3 Ostomy Supply Vendors Seattle Area: Choice Medical Supplies, Inc. 1215 E.

3 Page 3 Ostomy Supply Vendors Seattle Area: Choice Medical Supplies, Inc E. Union Seattle, WA th Ave. N.E., Suite 201 Bellevue, WA Phone: or Fax orders to: or (new orders) (Shipping available) Northwest Medical Supply 1530 N. 115 th, Suite 108 (Campus of Northwest Hospital) Seattle, WA Phone: Fax orders to: Questions? Your questions are important. Call your doctor or healthcare provider if you have questions or concerns. UWMC Clinic staff are also available to help at any time. Wound and Ostomy Care Service Other Mail Order Resources: AARP Pharmacy Service/Ostomy Care Center Care of 1810 Summit Commerce Park Twinsburg, OH Phone: for a catalog Fax orders to: (UPS shipment $4.75 charge) Shield Healthcare nd Ave. NE, Building 12, Unit H Redmond, WA Phone: Fax orders to: (UPS shipment no charge) Express Medical Supply, Inc. Catalog on Web site: P.O. Box 1164, 200 Seebold Spur Fenton, MO Phone: Fax orders to: (Free shipping on orders over $75; under $75 $6 shipment charge) Box N.E. Pacific St. Seattle, WA University of Washington Medical Center 05/2003

4 Page 4 Patient Name Address Physician Order for Ostomy Supplies Patient Sex M or F Telephone City Medicaid # State Zip Social Security # MEDICAL DIAGNOSIS Stoma Type Ileostomy Urostomy Colostomy Other (please explain) Date of Birth - - Date of Surgery - - Estimate length of need* (*Number of months; 99=lifetime) OSTOMY DISCHARGE PRESCRIPTION QUANTITY REFILL Ostomy Pouch PRN Ostomy Wafer PRN Stomahesive Paste PRN Stomahesive Powder PRN Eakin Wafer Convatec # PRN No-sting Skin Barrier Prep PRN Adhesive Remover PRN Ostomy Clip PRN Drainage Collector Bag PRN Ostomy Belt PRN Odor Eliminator PRN Please sign for insurance coverage: I authorize my insurance company (present and future) to release any information requested by pharmacy or medical supply company. I authorize my provider, whose name appears above, to furnish my insurance company with any information necessary to document my current illness or injury. I assign (name of pharmacy or medical supply company) all money to which I am entitled for services and equipment supplied by them. I understand that I am financially responsible for denied charges, any deductable owed, as well as charges not covered by this assignment. Patient Signature Date Number of Prescriptions Written Physician Number DEA Number Discharge Date Discharge Time Print Physician s Name Here Physician Signature (Substitution Permitted) Physician Signature (Dispense as Written) PT NO. UNIVERSITY OF WASHINGTON MEDICAL CENTERS HARBORVIEW MEDICAL CENTER UW MEDICAL CENTER SEATTLE, WASHINGTON NAME DOB

RE-CREDENTIALING PROFILE

RE-CREDENTIALING PROFILE ATTESTATION: All information on this profile is required for continued membership. Failure to provide required information will impact your membership status with Delta Dental