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Custom Garment Order Form

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COMPRESSION GARMENTS

Slider 01

Custom Garment Order Form

VIEW ALL
COMPRESSION GARMENTS

Custom Garment Order Form

All fields with * are required

PATIENT INFORMATION

First Name

Last Name

Phone Type

Phone Number

Prefered Method Of Contact

Email
Phone
Text (message and data rates may apply)

Gender

Male
Female

Address

City

State

ZIP

Date of Birth

INSURANCE INFORMATION

Policy Holder

Insurance Carrier

Policy Holder Employer

Policy Number

Policy Holder Employer Phone

Group Number

Policy Holder Date of Birth

Diagnosis Code (Primary)

Diagnosis Code (Secondary)

Must select at least one

Upper Body
Lower Body
Upper and Lower Body

Documentation required to process a custom garment order

1-Prescription dated within one year to include the items to be ordered.

A.compression rating (mmHg or Class of product)

B.quantity to be ordered and frequency of ordering.

a.Medicare and most plans cover 6 daytime garments per year

b.Medicare and most plans cover 2 nighttime garments per year

C.Your Diagnosis. Medicare now covers the following diagnosis codes for compression garments: I 89.0, Q 82.0, I 97.2 and I 97.89

2-Progress notes from your medical record, describing the treatments performed, items to be ordered and why a custom garment is needed instead of a ready to wear garment. Signed by your Therapist and dated within the past year.

3-A completed measurement form for the product(s) to be ordered, signed by the qualified person conducting the measurements

Click the Insurance Options Tab on our homepage for complete documentation requirements.

Your Message

Please Upload Any Relevant Documents (Prescription, clinical notes, measurement forms)

SunMED Product Search

SunMED Contact Info

SunMED Medical Systems
Address:
36 West Route 70, Suite # 214
Marlton, NJ 08053

Telephone: 800-714-7434
Fax: 800-715-5422

Departments:

Lymphedema/Compression 800-714-7434

Patient Accounts 855-477-4508