The VisiVest® Airway Clearance System Prescription Form

This order form is for The VisiVest Airway Clearance System only. Please use the other prescription forms if you are ordering a different product.

Patient Information

*required field

Patient First Name*

Patient Last Name*

Patient Date of Birth (MM/DD/YYYY)*

Patient Street Address*

City*

State*

Zip Code*

Patient Contact Name (if other than patient)

Relationship to Patient

Patient Phone Number*

Patient Email

Primary Diagnosis*

Secondary Diagnosis

Chest Measurement

Garment Style

Is the patient currently in the hospital?* Yes
No

If yes, what is their discharge date? (MM/DD/YYYY)

Patient Medicaid ID #

Patient Medicaid ID # is required for Medicaid beneficiaries in MA, MI, NJ, and NY

Protocol Information

Recommended Standard Protocol: Tx/Day: 2 | Minutes/Tx: 20 | Frequencies: 6-15Hz | Minimum usage/day: 10 minutes

Choose Standard or Custom Protocol Standard Protocol
Custom Protocol

For custom protocol, fill in the information below

# of Treatments per Day

Minutes per Treatment

Frequencies

Minimum Minutes of Use per Day

Length of Need

Other Protocol Notes

Prescriber Information

Do not add space before or after Prescriber First Name, Last Name, or NPI Number.

Prescriber First Name*

Prescriber Last Name*

Prescriber Email*

NPI Number*

Prescriber License #

Prescriber License # is required for prescribers in Pennsylvania

Clinic Information

Clinic Name*

Clinic Street Address*

City*

State*

Zip Code*

Clinic Phone Number*

Clinic Fax Number*

Clinic Contact Information

Clinic Contact Person

Clinic Contact Phone Number

Clinic Contact Email

Following Physician/PCP

Physician/PCP Phone Number

Physician/PCP Email

Patient Documentation

This section provides the option to upload patient specific documentation often required for processing an order or submitting to a payer. Maximum file size is 16mb for each option below. Documentation can also be faxed to 800-870-8452.

When required by the payer, documentation of a Face to Face Encounter with the patient within the last 6 months doucmenting the need for the product ordered (Required prior to delivery)

Copy of Patient's Insurance Card(s) (if available)

Patient Signed TCR (Terms, Conditions, and Responsibility)

Hospital Discharge Summary (if applicable)

Medical Records for the Past 6-12 Months. Include other airway clearance therapies tried and/or considered. Include reason(s) other airway clearance therapies were inappropriate, contraindicated, or failed

Include the below documentation for BRONCHIECTASIS PATIENTS only

Chest CT Imaging report confirming diagnosis OR Statement in Medical Record

Documentation in medical record of daily productive cough for at least 6 continuous months OR 3 or more exacerbations within the past year requiring antibiotic therapy

Forms

The Vest® Airway Clearance System Patient TCR (Terms, Conditions, and Responsibility) Form

Respiratory Health

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care