| DESCRIPTION | TYPE |
|---|
| Mobility Evaluation for wheelchairs and power wheelchairs: MEDICARE AND PRIVATE INSURANCES. This form must be completed by the prescribing physician or physician staff member in order to obtain insurance coverage for mobility equipment. The form should be filled out completely and returned to Charron Medical Services. | pdf |
| Mobility Evaluation for wheelchairs and power wheelchairs: NEW HAMPSHIRE MEDICAID ONLY. This form must be completed by the prescribing physician or physician staff member in order to obtain insurance coverage for mobility equipment. The form should be filled out completely and returned to Charron Medical Services | pdf |
| Prescription for Compression stockings: for Physician's offices that wish to prescribe compression stockings for their patients. This form must be completed in order to obtain insurance coverage for compression stockings. NOTE: Medicare DOES NOT cover prescription stockings, while most private insurance companies do (depending on the individual plan). | pdf |
| Nebulizer Request Form: for Physician's offices that have supply closets that are managed by Charron Medical. These are the forms that must be sent back to Charron Medical via fax with every Nebulizer that is dispensed. | pdf |
Wheelchair measuring guide: use this to take measurements for standard and lightweight wheelchairs. NOTE: if the patient has significant postural issues or there are existing pressure ulcers, please contact Charron Medical to arrange for a more advanced wheelchair fitting. | pdf |
| A Description of Coverage Criteria for Durable Medical Equipment for MEDICARE Beneficiaries. This is a brief description of how to obtain coverage and an explanation of the obscure and difficult to explain "capped rental" policy for wheelchairs and hospital beds. | word doc |
| Hospital Bed Order Form: to be filled out by referring physician and faxed back to Charron Medical along with prescription. | pdf |
| Compression Stocking Coverage Guide: A list of major insurances and the diagnoses required in order to obtain coverage for compression stockings. | pdf |
| CMN for Seat Lift Chair: to be filled out and returned via fax to Charron Medical | pdf |
| Physician's Guide to Mobility Products Coverage | pdf |
