Patient’s Name: Date of Birth: Medicaid ID # Medical Diagnoses:

Method of feeds: oral NG NJ-tube G tube GJ tube (need to qualify oral feeds) Is patient unable to reach or maintain weight and Yes height at the 10th percentile for age and sex without Please provide growth chart supplemental feeding? No Does patient have a disease or dysfunction of the Yes digestive tract, including dysphagia, which causes Describe: nutritional deficiency with insufficient nutrients to maintain body weight by impaired delivery of nutrients to the small bowel? No Formula Name: Total Volume for 30 days:

HCPC Code: ( on back) Amount required to meet 100% of daily estimated needs for one day, total Kcal/day______

Anticipated length of time needed: _____months

Method of Administration: *Must document reason of necessity for pump. Syringe Check all that apply (attach medical/clinical documentation) Gravity Severe diarrhea Pump* type:______Dumping syndrome Describe how feeds are administered: Reflux Continuous Aspiration Intermittent Blood glucose fluctuations Bolus Nissen ombination (explain)______Jejunal feeds Ventilated and/or trached Feeding difficulties (oral aversions)

______Date: ______Time: ______signature Statement of Medical Necessity:

______MD/LIP Contact #:______Date: ______

Enteral Nutrition Documentation Jan 09

DRUG DESCRIPTION HCPCS CODE DRUG DESCRIPTION HCPCS CODE FORMULA ALIMENTUM ADV BTL 32 OZ B4161 FORMULA NUTREN 1 VAN 1 CAL/ML B4150 FORMULA ALIMENTUM POWER B4161 FORMULA NUTREN 1.0 W/FIBER B4150 FORMULA BENEPROTEIN 8 OZ PWD B4155 FORMULA NUTREN 1.5 VAN 1.5 CAL/ B4152 FORMULA BOOST CHOCOLATE B4150 FORMULA NUTREN 2 VAN 2 CAL/ML B4152 FORMULA BOOST HI PROTEIN VANIL B4150 FORMULA NUTREN JR W/FIBER VAN B4160 FORMULA BOOST KID ESS 1.5 FBR B4160 FORMULA NUTREN JR. VANILLA B4160 FORMULA BOOST KID ESS 1.5 VAN B4160 FORMULA OPTIMENTAL VANILLA 8 OZ B4153 FORMULA BOOST PLUS CHOCOLATE B4152 FORMULA OSMOLITE 1.5 CAL 1L RTH B4152 FORMULA BOOST PLUS VANILLA 237 B4152 FORMULA OSMOLITE 1.5 CAL 240ML B4152 FORMULA BOOST VANILLA B4150 FORMULA OSMOLITE HN 1.06 CAL/ML B4150 FORMULA BOOST W/FIBER VANILLA B4150 FORMULA OSMOLITE HN RTH 1000 ML B4150 FORMULA BRIGHT BEGINNINGS SOY B4160 FORMULA OXEPA VANILLA 8 OZ B4154 FORMULA CARN G/START SUPR DHA B4158 FORMULA PEDIALYTE 32 OZ CHLD 12 B4103 FORMULA CARNA G/START SUPR PWD B4158 FORMULA PEDIASURE BANANA CREAM B4160 FORMULA CARNATION LF VANIL VHC B4152 FORMULA PEDIASURE CHOCOLATE B4160 FORMULA CERALYTE 90 LEMON 50 B4103 FORMULA PEDIASURE STRAWBERRY 8 B4160 FORMULA COMPLEAT 1.07 CAL/ML B4149 FORMULA PEDIASURE VAN 8 OZ 1 B4160 FORMULA COMPLEAT PED 1 CAL/ML B4149 FORMULA PEDIASURE W/FIBER VAN B4160 FORMULA DIABETISOURCE AC B4154 FORMULA PEDIATRIC EO28 GRAPE B4161 FORMULA DUOCAL UNFLVD POWDER B4155 FORMULA PEDIATRIC E028 ORG/PIN B4161 FORMULA ELECARE POWDER 14.1 OZ B4161 FORMULA PEDIATRIC 3028 TROPICA B4161 FORMULA ELECARE VAN PWD 14.1 B4161 FORMULA PEPDITE JR UNFLV PKT B4161 FORMULA ENF LF W/LIPIL 13 OZ B4158 FORMULA PEPTAMEN 1.5 UNFLVD B4153 FORMULA ENFACARE LIPIL 14 OZ PW B4160 FORMULA PEPTAMEN AF UNFLAV 250 B4153 FORMULA ENFAMIL AR W/LIPIL PWD B4158 FORMULA PEPTAMEN JR PREBIO VAN B4161 FORMULA ENFAMIL GENTLEASE PWD B4158 FORMULA PEPTAMEN JR UNFLAV 1 B4161 FORMULA ENFAMIL LIPIL W/FE PWD B4158 FORMULA PEPTAMEN JR VAN 1 CAL B4161 FORMULA ENSURE CHOC 1.06 CAL/ML B4150 FORMULA PEPTAMEN JR W/FIBER VA B4161 FORMULA ENSURE PLUS CHOC B4152 FORMULA PEPTAMEN UNFLV 250 ML B4153 FORMULA ENSURE PLUS B4152 FORMULA PEPTAMEN VANILLA B4153 STRAWBERRY FORMULA ENSURE PLUS VAN 8 OZ 50 B4152 FORMULA PEPTAMEN W/PREBIO VANI B4153 FORMULA ENSURE STRAWBERRY 1.06 B4150 FORMULA PEPTINEX 1.5 VANILLA B4153 FORMULA ENSURE VAN 1.06 CAL/ML B4150 FORMULA PEPTINEX DT PED 250 ML B4161 FORMULA ENSURE W/FIBER VAN 1 B4150 FORMULA PEPTINEX DT PED/FIBER B4161 FORMULA FIBERSOURCE HN 250ML B4150 FORMULA PHENEX 2 PWD (>12) S9435 FORMULA GLUCERNA 8 OZ 1 CAL/ML B4154 FORMULA PHENEX 2 VAN PWD (>12) S9435 FORMULA GLYTROL DIAB VANILLA B4154 FORMULA POLYCOSE POWDER 746 2. B4155 FORMULA GOOD ST 2 S/SOY 24 OZ B4159 FORMULA PORTAGEN PWD 1 LB (>12) B4150 FORMULA GOOD ST 2 SUPR SOY PWD B4159 FORMULA PORTAGEN PWD 1 LB <=12 B4158 FORMULA GOOD START NATURAL CUL B4158 FORMULA PREGESTIMIL PWDR 1 LB 1 B4161 FORMULA IMPACT W/FIBER B4154 FORMULA PRO-PHREE PWD 350 GM B4155 FORMULA ISOMIL ADV W/FE LF PWD B4159 FORMULA PROMOTE 8 OZ 1 CAL/ML B4150 FORMULA ISOMIL W/FE PWD 12.9 OZ B4159 FORMULA PROMOTE W/FIBER 8 OZ 1. B4150 FORMULA ISOSOURCE 1.5 CAL B4152 FORMULA PROPIMEX 2 PWD (>12) S9435 FORMULA ISOSOURCE HN VANILLA B4150 FORMULA PROSOBEE LIPIL PWD B4159 FORMULA JEVITY 1 RTH 1000ML B4150 FORMULA PULMOCARE VAN 1.5 CAL/M B4154 FORMULA JEVITY 1.2 1500 ML BTL B4150 FORMULA RCF LOW IRON SOY 81 CAL B4155 FORMULA JEVITY 1.2 RTH 1000 ML B4150 FORMULA RENALCAL 2 CAL/ML B4154 FORMULA JEVITY 1.5 RTH 1000 ML B4152 FORMULA REPLETE W/FIBER VAN B4150 FORMULA JEVITY 8 OZ 1 CAL/ML B4150 FORMULA RESOURCE GLUTASOLVE B4155 FORMULA JEVITY 8 OZ 1.2 CAL/ML B4150 FORMULA RESOURCE JFK W/FIBER B4160 FORMULA JEVITY 8 OZ 1.5 CAL/ML B4152 FORMULA RESOURCE JUST FOR KIDS B4160 FORMULA KETOCAL 4:1 300 GM PWD B4154 FORMULA RESOURCE PEACH 186400 B4150 FORMULA KINDERCAL TF W/FIBER B4160 FORMULA SCANDISHAKE CHOCO 3 OZ B4152 FORMULA MCT OIL 32 OZ B4155 FORMULA SIMILAC ADV/FE RTF 32 B4158 FORMULA MICROLIPID 89 ML 400 CAL B4155 FORMULA SIMILAC ADVANCE/FE PWD B4158 FORMULA NEOCATE INFANT POWDER B4161 FORMULA SIMILAC NEOSURE ADV PW B4160 FORMULA NEOCATE JR POWDER B4161 FORMULA SIMILAC PM 60/40 16 OZ B4154 FORMULA NEOCATE JR TROP FR PWD B4161 FORMULA SUPLENA CARB STEADY B4154 FORMULA NEOCATE ONE+ 60 GM PWD B4161 FORMULA TOLEREX 80 GM B4153 FORMULA NEOCATE ONE+ PWD PKT B4161 FORMULA TWOCAL HN VAN 8 OZ 2 B4152 FORMULA NEPRO W/CARB STEADY VA B4154 FORMULA VITAL HN PWDR 766 1 B4153 FORMULA NEXT STEP LIP PWD 24 B4158 FORMULA VIVONEX PED PWDR B4161 FORMULA NEXT STEP PROSOB LIP24 B4159 FORMULA VIVONEX RTF 1000 ML B4153 FORMULA NOVASOURCE RENAL 8 OZ B4154 FORMULA VIVONEX TEN PWDR B4153 FORMULA NUTRAMIGEN PWDR 1LB 10 B4161