Back, Shoulder, Wrist, Ankle and Neck Brace Packet

Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD

Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org

Brace Order Sheet

Patient NameMRN #Insurance# of Braces PrescribedAuthorization #Start date:Order date (if different than start date):

Check each brace being ordered. The matching acknowledgment page and ABN line are added below automatically.

Physician Name

Physician Signature

Printed nameDate

Patient Signature

Printed nameDate

The patient has been advised to begin using their brace today. Date:

Dispensed Facility Address:Other address:

Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD

Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org

Acknowledge receipt of Lumbar Sacral Orthosis, HCPCS Code L0650

Patient Full Name:Patient Address:

(initials) acknowledge receipt of Lumbar Sacral Orthosis, HCPCS Code L0650
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Prescribing Physician’s Name:Brace Serial#:

Dispensed Facility Address:Other address:

Start Date:Number of Brace(s) given:Order Date (if different than start date):

Instruction: Direction for Back Brace use: Received:

Yes (initial)
No (initial)

Patient Signature & Date

Printed nameDate

Physician Signature

Printed nameDate

Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD

Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org

Acknowledge receipt of Shoulder Orthosis, HCPCS Code L3670

Patient Full Name:DOB:Patient Address:

(initials) acknowledge receipt of Shoulder Orthosis, HCPCS Code L3670
Shoulder orthosis (SO), acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf

Prescribing Physician’s Name:Brace Serial#:

Dispensed Facility Address:Other address:

Start Date:Number of Brace(s) given:Order Date (if different than start date):

Instruction: Direction for Shoulder Brace use: Received:

Yes (initial)
No (initial)

Patient Signature & Date

Printed nameDate

Physician Signature

Printed nameDate

Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD

Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org

Acknowledge receipt of Wrist Hand Orthosis, HCPCS Code L3908

Patient Full Name:DOB:Patient Address:

(initials) acknowledge receipt of Wrist Hand Orthosis, HCPCS Code L3908
Wrist hand orthosis (WHO), wrist extension control cock-up, non molded, prefabricated, off-the-shelf

Prescribing Physician’s Name:Brace Serial#:

Dispensed Facility Address:Other address:

Start Date:Number of Brace(s) given:Order Date (if different than start date):

Instruction: Direction for Wrist Brace use: Received:

Yes (initial)
No (initial)

Patient Signature & Date

Printed nameDate

Physician Signature

Printed nameDate

Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD

Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org

Acknowledge receipt of Cervical Collar, HCPCS Code L0180

Patient Full Name:DOB:Patient Address:

(initials) acknowledge receipt of Cervical Collar, HCPCS Code L0180
Cervical, multiple post collar, occipital/mandibular supports, adjustable

Prescribing Physician’s Name:Brace Serial#:

Dispensed Facility Address:Other address:

Start Date:Number of Brace(s) given:Order Date (if different than start date):

Instruction: Direction for Neck Brace use: Received:

Yes (initial)
No (initial)

Patient Signature & Date

Printed nameDate

Physician Signature

Printed nameDate

Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD

Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org

Acknowledge receipt of Walking Boot, HCPCS Code L4361

Patient Full Name:DOB:Patient Address:

(initials) acknowledge receipt of Walking Boot, HCPCS Code L4361
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf

Prescribing Physician’s Name:Brace Serial#:

Dispensed Facility Address:Other address:

Start Date:Number of Brace(s) given:Order Date (if different than start date):

Instruction: Direction for Walking Boot use: Received:

Yes (initial)
No (initial)

Patient Signature & Date

Printed nameDate

Physician Signature

Printed nameDate

A. Notifier: Garden State Medical Center, 1314 Hooper Avenue, Bldg B, Toms River, NJ 08753 Phone: (732) 202-3000 Fax: (732) 849-0015

B. Patient Name:C. Identification Number:

Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If Medicare doesn’t pay for D. brace (durable medical equipment) below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. brace (durable medical equipment) below.

OPTIONS: Check given brace box. We cannot choose a box for you.

D. Durable Medical Equipment

L0650 Back orthotic: Lumbar-sacral orthosis (LSO). L3670 Shoulder orthosis (SO), acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf. L3908 Wrist hand orthosis (WHO), wrist extension control cock-up, non molded, prefabricated, off-the-shelf. L0180 Cervical, multiple post collar, occipital/mandibular supports, adjustable. L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf. OTHER:

E. Reason Medicare May Not Pay:

Medicare will pay for one orthotic every five years of a particular type of brace.

Medicare has declared your condition medically unnecessary for this type of orthotic.

Medicare has decided that this orthotic is a noncovered service.

F. Estimated Cost

(Must be included prior to patient signature)

$

WHAT YOU NEED TO DO NOW:

Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the D. brace (durable medical equipment) listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the D. brace (durable medical equipment) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. brace (durable medical equipment) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don’t want the D. brace (durable medical equipment) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).

Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature

Printed nameJ. Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131

Back, Shoulder, Wrist, Ankle and Neck Brace Packet

Brace Order Sheet

Back Brace: (LSO – L0650)

Shoulder Brace (L3670)

Wrist (L3908)

Neck Brace (L0180)

Ankle walking boot (L4361)

Acknowledge receipt of Lumbar Sacral Orthosis, HCPCS Code L0650

Acknowledge receipt of Shoulder Orthosis, HCPCS Code L3670

Acknowledge receipt of Wrist Hand Orthosis, HCPCS Code L3908

Acknowledge receipt of Cervical Collar, HCPCS Code L0180

Acknowledge receipt of Walking Boot, HCPCS Code L4361

Advance Beneficiary Notice of Non-coverage (ABN)

D. Durable Medical Equipment

E. Reason Medicare May Not Pay:

F. Estimated Cost

WHAT YOU NEED TO DO NOW:

Send your packet to our office

Talk with a GSMC specialist