<p> R&M REYES ENTERPRISE, LLC 99-899 Iwaena Street Unit 111 Aiea HI 96701 Phone: (808) 676-7661 Fax: (808) 380-2893 or Email: [email protected]</p><p>Physician: Please complete all sections and fax with supporting medical records to R&M REYES ENTERPRISE, LLC F: (808) 380-2893</p><p>Patient Name: Date of birth: </p><p>Diagnoses (ICD-10 Codes and Descriptions): </p><p>Date of Injury: Surgery? YES or No: If so when? </p><p>L3900 -WHFO L3766-PRO/SUP L3766-ESP L3730-ELBOW FLEX/EXT L1844 -KNEE</p><p>To be provided by: R&M REYES ENTERPRISE, LLC Effective: (Original Order Date + “Lifetime”) ROM Parameters & Precautions:______DME Purchase? ____Yes ____No To Order a Stat-A-Dyne ROM product or Vector 1 Hand CPM, R&M Reyes will need the following patient information: 1. Patient demographic information (Address, DOB, Phone #, Insurance Information) 2. Prescription (LMN) from the ordering physician. *Medicare patients require a Detailed Written Order from their physician. 3. Recent Physician and Therapy notes. 4. Custom Measurement form (provided by R&M Reyes)</p><p>Physician Signature (No Signature or Date Stamps please)</p><p>For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered. By signing below, I am stating:  I am/was treating the above-referenced patient.  The information on this written order accurately reflects the patient’s condition and the device I am prescribing.  My medical record for this patient substantiates the prescribed use of the product.  I will maintain a signed copy of this order in the patient’s medical record file and make it available for Medicare/Insurer audit purposes. R&M REYES ENTERPRISE, LLC 99-899 Iwaena Street Unit 111 Aiea HI 96701 Phone: (808) 676-7661 Fax: (808) 380-2893 or Email: [email protected]</p><p>MEDICAL NECESSITY CERTIFICATION I, the undersigned, certify that the above prescribed equipment is medically necessary for this patient's well-being. The equipment is both reasonable and necessary in reference to accepted standards of medical practice in the treatment of this patient's condition and is not prescribed as "convenience" equipment. </p><p>NO SUBSTITUTIONS ALLOWED. In my opinion, in accordance with accepted medical practice standards, the above named patient requires the exact Stat-a-Dyne or Vector1 product as dispensed by Lantz Medical/R&M Reyes Enterprise, LLC for the diagnosis indicated.</p><p>Physician Signature: Date:</p><p>Physician Printed Name: NPI: Address: Phone #: Fax #: </p>