Create A Letter of Medical Necessity

By entering information below, the DoctorBach website will build a customized sample Letter of Medical Necessity. When a diagnosis of SMA Type 1 is selected below, other values will be changed to SMA1 sample settings. Click Clear Changes to return to non-SMA1 sample settings. When finished, click Submit.

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The information entered is not stored, it is used only for creating the sample letter.

Patient Information

Diagnosis:
Name:
Age: Years Old   Months Old
Sex: Boy   Girl   Man   Woman
Last Exam:

Examination Findings

Inspiratory Muscle... Failure     Dysfunction
For SMA1: Paradoxical chest wall motion
    (If VC is blank, no results will be displayed)
Sitting Vital Capacity (VC): ml % of normal
Supine Vital Capacity: ml
Maximum Insufflation Capacity (MIC): ml
Peak Cough Flow (PCF) from MIC: L/s
PCF from MIC with Abdominal Thrust: L/s
SaO2 Range: % to %
End-Tidal pCO2: mm Hg
Other:

Intervention

Trained: Patient     Family     Caregiver
Trained in nasal IPPV
Trained in mouthpiece IPPV
Trained in manually assisted coughing
Trained in mechanical in-exsufflation
Practice Air Stacking
Practice Sliding Board Transfers
Discontinue BiPAP
Patient Given Ambubag
Other:

Equipment Needs

Portable volume ventilator (PLV-100)
        Day     Night
    Mode:
    Volume: ml
    Rate: bpm
BiPAP-ST (night use)
    IPAP:
    EPAP:
    Rate: bpm
Oxymeter
Mechanical In-Exsufflator (In Home)
Mechanical In-Exsufflator (Rapid Access)
Manual Recuscitator
Chest Percussor
Portable Suction Equipment
Other:

Physician Information

Name:
Title:
Clinic/Hospital:
Phone:
 


Create A Letter of Medical Necessity
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