b"C-Section & Postpartum Recovery Order FormThis document serves as a Prescription and Statement/Certificate ofMedical Necessity for the referenced patient.Patient InformationPatient Name: Address:State: Zip: DOB:Height: Weight: Phone #:Email: JANZ location: Patient Insurance Information This section can be left blank if accompanied by a copy of the patient's insurance card.Insurance Type: TRICARE VA FMP AETNA/AFSPA FEP BCBSMember ID/SSN/Benefits #: Diagnosis InformationDX Code:Length of Need (Not to Exceed 8 weeks): Statement of Medical NecessityHad/Will have a C-Section? Yes NoWas this an elective procedure? Yes NoWas there birthing issues that would have affected the safety of the mother? Yes NoAdditional medical reason contingent upon recovery:C-Section Post-Partum TherapyMotif Stage 1 Heal C-Section Waterproof Anti-Adhesion Dressing with PU Foam (A6212) (1st Week)Motif Stage 2 C-Section Dressing System Surgical Hydrogel Patch (6245) (Week 2-6)Motif Stage 3 C-Section Dressing System Scar Care Dressing (A6213) (Week 7-24)Motif Postpartum C-Section & Compression Garment (L2630 / A4467) ABD Pads (A6206):McKesson 5x9 ABD Pad (A6252)Medline ABD Pad (A6252) Renasys Adhesive Gel Patch (A6234) Quantity:Smith & Nephew Skin Barrier Cream (A6250)Quantity: Smith & Nephew Alcohol Prep Pads (A4245) Quantity:Non-Adhering Tape (A9900 XG): Hypafix Tape (A4452)Quantity:McKesson Non-Woven Gauze (A6404)Quantity:Prescribing Physician InformationPhysician Name: Date:Physician Signature: NPI:Fax Number: Physician Address:Phone Number:www.janzmedicalsupply.com"