b"Compression & Support Order FormThis document serves as a Prescription and Statement/Certificate ofMedical Necessity for the referenced patient.Patient Name: Date: DOB: Baby DOB/Due Date: Address: Phone Number:Sponsor Name: Sponsor SSN:Benefits #: Insurance:Compression Socks & PantyhoseA6530 Compression Stocking Below the Knee (20-30mmHg)Size: A6533 Compression Stocking Thigh Length (20-30mmHg)SmallLarge MediumX-Large A6539 Compression Pantyhouse (20-30mmHg)Color: Diagnosis Codes: Please check the appropriate boxBlackVaricose veins O22.00 Nude Asymptomatic varicose of bilateral lower ex. I83.93Other Diagnoses:Quantity:Pelvic/Sacral SupportL0621 Maternity Support BeltSize: L2630 Postpartum / C-Section GarmentSmallLarge Diagnosis Codes: Please check the appropriate boxMediumX-Large O90.00 C-section wound Color: M54.5 Low back pain BlackM54.17 Radiculopathy, lumbosacral region Nude O26.899 Round ligament painM46.06 Spinal enthesopathy, sacral & sacrococcygealQuantity:R10.20 Pelvic joint painO22.10 Vulvar varicosityOther: Physician name: Physician's signature:NPI: Phone Number:Fax Number:www.janzmedicalsupply.com"