Download TENS UNIT INTAKE FORM

200- 2 TENS Intake
TENS UNIT INTAKE FORM
 Date written order was received. ___________________________
Do not deliver prior to receiving written order.
 Patient’s diagnosis __________________________
Not covered if ordered for:
1. Headache 2. Abdominal pain 3. Pelvic (hip) pain
 What type of tens unit?
2 Lead
4. TMJ
4 Lead
If 4 leads are ordered:
Why 2 are leads insufficient to meet the patient’s needs.
REASON: _______________________________________
We must obtain written reason from physician or qualified professional.
 Is the tens unit being ordered for post operative pain? Yes
No
If yes: Date of surgery: ______________________
Medical necessity for post-op pain is limited to 30 days from surgery date.
--OR- Does patient have chronic, intractable pain? Yes
No
If yes: How long has patient had pain? ___________________
Pain must be present for at least 3 months to qualify.
 Is there documentation of other types of medications and/or therapies that have
been tried and failed?
Yes
No--If No patient will not qualify.
 Trial/ rental will be covered for at least 30 days not to exceed 2 months.
 Electrodes are not paid separately during the rental period.
 Purchase can be authorized after the trial period (31st or 61st day).
Rev 7/2005