Hock's Pharmacy
	535 South Dixie Drive   Vandalia, Ohio 45377
	800 866 4997 voice      937-898-9340 Fax-----Print This form
	WRITTEN CONFIRMATION OF VERBAL ORDER FOR DIABETES TESTING SUPPLIES
	Instructions: Please fill in ALL Sections 1-7 and make any necessary changes to reflect the current regimen prescribed for your patient, initial any changes, and sign and date below to confirm this ongoing course of treatment.
	Order Date_____/_______/_________
	Medicare maximum allowed duration of need is 12 months. Duration of Need______ if not otherwise specified (NOS), then 12 months.
	Patient Name_____________________________ D.O.B.__________________ SS#_________________________ Address______________________________________________________________________________
	1.  Patient is attempting to control their form of diabetes with insulin injections?  Yes___No___
	2.  Diagnosis Code:_________________ Other:____________________
	3.  Patient's testing frequency per day? _______(Medicare does not accept PRN)             [Number of strips and lancets prescribed for a 90 day period equals 1 x day=100             (2 x day=200) 3 x day=300 (4x day=400) 5 x day=450]
	3a.  Medicare requires an explanation for testing more frequently than;             1 x day non-insulin dependent or 3 x day insulin treated:Therefore: I confirm that I have seen this patient             within the last six (6) months to evaluate their diabetes control and have noted below the reason(s) for high             testing frequency             _______________________________________________________________________________________             _________________________________________________________________________________
	4.  I prescribe the following Diabetes Supplies.           Test Strips               Lancets                                Control Solution               Lancet Device            Battery                     Glucose Monitor               Alcohol Wipes               Insulin/Syringes (if injecting insulin).
	By my signature below, I confirm that the patient has diabetes and is/was being treated by me. All the information contained on this Doctor's Order Form accurately reflects the patient's diabetic condition and the treatment regimen that I have prescribed. The medical records for this patient substantiate the prescribed testing frequency. The patient/caregiver is able to follow instructions for controlling diabetes and is able to use the ordered items. For medicare/Insurance requirements. l will maintain this signed original document in the patient's medical record file for post-payment review/audit purposes.
	5.  Physician's Signature_______________________________________6. Date_______/______/_________
	7.  Physician UPIN Number___________________________________
	Physician Name_______________________________ Address:______________________________________________________________ Physician Phone:_______________________________   Physician Fax #:________________________________