Patient Info
Patient Insurance Info
Product Description

Double truss with standard pads, 8" wide medical grade, latex free, anti-microbial abdominal, pelvic-sacral and lumbar support secured by attached compression shorts with 3 attached and adjustable pelvic floor/perineum/hernia elastic tension straps. Removable pouches with gel packs for cryotherapy or heat therapy, in combination with compression to reduce pain, swelling and pressure for the lumbar, hips abdomen and perineum.

For sizing, reference sizing guide at www.mamastrut.com/sizing-care

Provider Info

Please ensure # is correct as we will be faxing/calling this number

Diagnosis
DOI
(same as signing date)
Device
Supporting Clinical Notes

I certify that I am the physician/practitioner identified on this form. I have reviewed the Certificate of Medical Necessity. Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge. I certify I am qualified, under CMS guidelines, to sign and prescribe medical equipment and supplies. I certify that the patient/caregiver is capable and has successfully completed training or will be trained on the proper use of the products prescribed on this Written Order. The patient’s record contains supporting documentation that substantiates the utilization and medical necessity of the products listed and physician notes and other supporting documentation will be provided upon request. I understand any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient’s medical record.