6554 Florida Blvd, Ste 123
Baton Rouge, LA 70806
p 800-256-9979 f 866-455-5150
www.vasocare.com
Physician’s Written Order
AFFLOVEST
Physician
Patient
Prescribing Physician Name:___________________________
First Name:__________________ Last Name:_______________ MI: ____
Street Address:_____________________________________
City:______________________ State:______ Zip:_________
Phone #:___________________ Fax #:__________________
NPI #:____________________________________________
Phone #:____________________ DOB:_____________ Gender: □ M □ F
Address:_____________________________________________________
City:____________________________ State:_______ Zip:____________
Email Address:_______________________________________________
Treatment History
Which of the following treatment methods have been tried and failed?
□ CPT (Manual of Percussor)
□ Breathing/Drainage Techniques
□ PEP
□ Flutter/Acapella
□ Cough Assist
□ Other______________________________________________
Check all the reasons the above treatment failed, is inappropriate, or contraindicated.
□ No caregiver available
□ Too fragile for percussion
□ Can’t tolerate positioning
□ Kyphosis/Scoliosis
□ Cognitive level
□ Physical limitations of caregiver □ Physical limitations of patient □ GERD
□ Did not mobilize secretions □ Resistance to therapy
□ Young Age
□ Insufficient expiratory force □ Severe arthritis/osteoporosis □ Aspiration Risk
□ Spasticity/Contracture
□ Inability to form mouth seal □ Artificial airway
□ Other __________________________________________________
Medical History
Within the past year, has the patient had any of the following?
□ Atelectasis
□ Decline in pulmonary function
□ Physical limitations of patient
□ 2+ exacerbations requiring antibiotics
□ Resistant bacteria found in sputum □ ER visits for pulmonary exacerbations
□ Mucus plugs
□ Hospitalizations for pulmonary exacerbations
□ Respiratory infection
If more than two exacerbations requiring antibiotics, select whether oral, intravenous, or both. □ Oral □ IV
For bronchiectasis patients, is there a CT scan confirming bronchiectasis diagnosis?
□ Yes □ No
Diagnosis Codes
Treatment Protocol
Bronchiectasis - □ 494.0 □ 494.1 □ 748.61
Cystic Fibrosis - □ 277.00 □ 277.02
□ Standard
____2_____
Anterior horn cell diseases - □ 335.0 – 335.9 ________
Treatments per day
Quadriplegia - □ 344.00 – 344.09 ________
Minutes per Treatment
Multiple Sclerosis - □ 340
____30____
__10-20 Hz_
Muscular dystrophy - □ 359.0 □ 359.1
Other - □ ______________________________
Frequencies/Intensities
____2 ____
Minimum Use Per Day
□ Custom
Est Length of Need = ________ mo
__________
(99 = Lifetime)
Treatments per day
Circumference
Pectoral line ___________ (in)
Abdomen ___________ (in)
__________
Minutes per Treatment
__________
Frequencies/Intensities
__________
Minimum Use Per Day
Measure across the largest part
of the chest/abdomen with arms
at patient’s side
Rx: The AffloVest Airway Clearance System, HCPCS E0483
I certify the accuracy of this Rx for the AffloVest Airway Clearance System and that I am the physician identified in this form. I certify that the medical information
provided above and in the supplementary documentation is true, accurate, and completed to the best of my knowledge. The patient record contains the
supplementary documentation to substantiate the medical necessity of the AffloVest.
_____________________________________
__________________________________
Physician Signature (no signature stamp)
Physician’s Printed Name
_______________
Date
Please fax signed Rx, Progress Notes, and Face Sheet to 866-455-5150