Prescription steps and forms

Below are the forms needed to prescribe high frequency chest wall oscillation (HFCWO), and to obtain HFCWO authorization and reimbursement from most insurance providers. These forms were designed with extensive input from both clinicians and payers to capture and format prescription details in ways that enhance efficiency and accuracy.

Step 1

Complete the Patient Demographics Form.

Step 2

Complete the SmartVest® System Prescription and Certificate of Medical Necessity form. Here’s a sample illustrating proper completion of this form.

Step 3

Obtain patient’s signature on Patient Agreement and Consent Form (a HIPAA requirement). If your patient is not present to sign, Electromed will obtain this release directly from the patient.

Step 4

If you’re treating a Medicare patient, note Medicare Requirements for Bronchiectasis, Cystic Fibrosis and Neuromuscular Conditions.

Step 5

Fax these forms to Electromed: 866.758.5077

Electromed, Inc. will manage the process from there, including:

  • Confirming active insurance coverage.
  • Obtaining from the patient and/or caregiver any additional health status or history information required by the insurance provider.

Electromed has a team of specialists to help clinicians, patients, caregivers and payers navigate the documentation and communication necessary to prescribe and reimburse the SmartVest Airway Clearance System. For questions and assistance, contact Electromed’s Reimbursement Team.