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FEATURE

Health Benefits

Specifications

Community medical equipment inc
DBA compression medical supplies

specializing in lymphedema &
venous disorders

bio compression systems

order form fax#: +1(718)-208-4130

DATE OF ORDER:

Patient Name:

DOB:

Patient Phone no:

Insurance Plan:

Insurance ID#:

Extremities for Treatment: LEGS:

LT:

RT:

With Abdomen (Lympha Pants) ARMS:

LT:

RT:

With Trunk (Comfy Sleeve)

Special request:

TREATMENT: Pressure

frequency

/Day

MIN

Length of necessity :

Months (99=Lifetime)

default settings: 40mmHg, TID/BID, 60 min

Q82.0 HEREDITARY LYMPHEDEMA

I89.0 SECONDARY LYPHEDEMA DUE TO

VENOUS INSUFFICENCY

TUMOR (S)

SCARRING OF THE LYMPH CHANNELSFROM CELLULITIS AND/OR LYMPHANGITIS

CANCER SURGERY AND/OR RADIATION

OTHER

POST MASECTOMY SYNDROME

CHRONIC VENOUS INSUFFICIENCY

Varicose vein with ulcer

Venous hypertension with an ulcer

PRESCRIBING PHYSICIAN:

OUR Instructions

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Community Medical Equipment DBA Compression Medical Supplies

BOC Accredited

270 Woodland Ave, 1st Floor, Yonkers, NY 10703

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