Patient Insurance Case Study

Patient Insurance Information
PleurX® Drainage Kits

Patient Information: Complete the following section or attach the patient’s face sheet.
Patient Name: Last__________________________________ First______________________________________ M.I.____________
Patient Phone:______________________________________________________________________________________________________
Alternate Contact Name:_______________________________________________________ Phone:_____________________________
Address:____________________________________________________________________________________________________________
City:_______________________________________ State:_______________________________ ZIP:____________________________
Insurance Information:
361-24111

Detailed Written Order
PleurX® Drainage Kits
Section A:
Patient Name:______________________________________________________ D.O.B.:___________________ Sex:______ M_______F
Phone:_______________________ Patient Address:_____________________________________________________________________
City:_______________________________________ State:_______________________________ ZIP:____________________________
Physician:____________________________________________________________________ Phone:_____________________________
Physician Address:__________________________________________________________________________________________________
City:_______________________________________ State:_______________________________ ZIP:____________________________
Place of Service: Home
Section B: Please Review and/or Complete

Primary Diagnosis — Location of Fluid Accumulation (required)
Diagnosis (ICD-9) Please Check Appropriate Diagnosis:

511.9 Unspecified Pleural Effusion

789.51 Malignant Ascites