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Certificación del Médico para Zapatos Terapéutico Pág 1 de 1 Rev. 03/2015 Certificación del Médico para Zapatos Terapéuticos Nombre del… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 03/2015  Expedita  Estándar Enviar al número de fax: (787) 620-0925 / 0926 Coordinación de Servicios de Alta… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Urgente (Expedita) Rutina (Estándar) Masculino Alergias: Referido a: Glucómetro Diario Lancetero 2 veces al día Tirillas 3 veces al dia… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Notificación de Medicare de No-Cobertura Nombre del Paciente: ________________ Número de ID del Paciente:____________ La fecha en que comenzó la… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Face to Face Examination Pag 1 – 2 Rev. 01/2015 Face To Face Patient Name: _______________________ Member ID: ____________________________ Address:… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 3/2015 Certificate of Medical Necessity Bath Chair Section A: General Information Certification: Initial: Revised:____/____/____ Patient Name: Customer ID #:… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 3/2015 Certificate of Medical Necessity Sphygmomanometer Section A: General Information Certification: Initial: Revised:____/____/____ Patient Name: Customer ID #: Address:… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 3/2015 Certificate of Medical Necessity for Non-Emergency Ambulance Transportation Section A: General Information (to be completed by the Ambulance… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Statement of Certifying Physician for Therapeutic Shoes Page 1 of 1 Rev. 03/2015 Statement of Certifying Physician for Therapeutic Shoes… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Please fax to 787-993-3265 Y0082_2082_15_CI_07_S Page 1 of 3 Rev. 09/2014 Please fax to 787- 993-3265 If in doubt or… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)