Diagnosis - To Be Completed by Healthcare Provider
Pelvic and perineal pain
Lower Abdominal, inguinal, groin pain
Other specified obtetric trauma (Diastasis Recti)
Acute or chronic pain in the lumbar or sacral regions
Hip Pain R/L
Contusion of vagina and vulva
First degree perineal laceration during delivery
Second degree perineal laceration during delivery
Third degree perineal laceration during delivery
Fourth degree perineal laceration during delivery
Anal sphincter tear complicating delivery, not associated with third degree laceration
Female genital prolapse
Incomplete uterovaginal prolapse
Complete uterovaginal prolapse
Uterovaginal prolapse, unspecified
Other female genital prolapse
Incompetence or weakening of rectovaginal tissue
Duration of need
Healthcare Provider Must Answer
*Questions regarding a previous delivery must be answered accordingly for all patients, including first-time moms.
Does the patient suffer from pelvic floor dysfunction or incontinence?
Did the patient suffer with recurrent/persistent low back pain with this pregnancy?
Does the patient have genital prolapse?
Does the patient have a BMI over 30 with an increased wound infection risk?
Does the patient have severe diabetes and a history/or increased risk for wound infections, slow healing wounds?
*Did the patient have a 3rd or 4th degree vaginal tear with a previous delivery?
*Did the patient have a breakdown of the suture, opening of skin with infection in a previous delivery?
*Did the patient have an episiotomy with a previous delivery?
*Did the patient have a rectal fissure repaired after a previous delivery?
*Did the patient have a prolonged recovery from a vaginal tear in a previous delivery?
*Did the patient have a prior c-section with wound infection and/or wound disruption?
*Does the patient have diastasis or hernia from a prior c-section or vaginal delivery?
Product & Sizing
MamaStrut Postpartum Care System
Measure below the belly and around the pelvis/hips.
Postpartum/Post-op: 8" wide medical grade quality, latex free, anti-microbial abdominal, pelvic-sacral and lumbar support secured by attached compression shorts for maximum stability with 3 attached and adjustable pelvic floor/perineum/hernia elastic tension draps. Usewith or wtlhout adjudable tension straps to customize placement and amount of support. Removable and adjustable pouch 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. Latex free.
I certify that I am the physician/practitioner identified on this form. I have reviewed the Physician’s Written Order. 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 to CompCare Health, Inc. 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.
This fax message and any attachments may contain confidential information. If you are not the intended recipient and have received this message in error, please inform sender and delete the contents without copying, distributing or forwarding. By faxing this form you are acknowledging that the patient is aware that an Edgepark Representative may be contacting them for any additional information to process this order. Thank you.
Forms must be sent with supporting clinic notes verifying medical necessity.
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