Beneficiary Information

Please provide the required patient information to ensure accurate CMS documentation for wound care supplies. All fields marked with an asterisk (*) are mandatory.

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(in Evaluation specify

Patient Name *

Medical Record Number (MRN) *

Date of Birth (DD/MM/YYYY) *

Medicare Beneficiary Identifier (MBI) *

Order Date (MM/DD/YYYY) *

Type of Wound Care Item Ordered *

• Gauze
• Hydrogel
• Foam Dressing
• Alginate Dressing
• Negative Pressure Wound Therapy (NPWT)
• Other

If Other, please specify

Quantity Ordered *

HCPCS Code (if known)

Brand/Model (if known)

Medical Necessity Justification *

Supporting Documentation Available in ChartYesNo

Prescribing Practitioner Name *

NPI *

Signature *

Clear Signature

Date of Signature (DD/MM/YYYY) *

Primary Diagnosis (ICD-10)

Wound Type and Description

Clinical Rationale for Product Use

Wound Care Goals

• Promote healing
• Prevent infection
• Manage exudate
• Other

If Other, please specify

Date of Evaluation (DD/MM/YYYY)

Additional Clinical Notes (if applicable)

Type of Wound Care Product(s)

• Type of Wound Care Product(s)
• Foam Dressing
• Gauze
• Alginate
• Antimicrobial
• Other

If Other, please specify

Quantity Ordered

Frequency of Use

Duration of Use

Additional Notes

Wound Type *

• Pressure Ulcer
• Surgical Wound
• Diabetic Ulcer
• Other

If Other, please specify

Wound Location *

exmp: Left heel, sacral region, etc.

Wound Size *

exmp: 3cm x 2cm x 1cm

Wound Duration (in days) *

Signs of Infection Present? *

• Yes
• No

Drainage TypeSerousPurulentSanguineousNone

Wound Treatment Plan *

Physician Clinical Notes *

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