Hospital Beds KEYSTONE MOBILITY INC. HARRISBURG, PA 1 (800) 858-3060

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Hospital Beds

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General Requirements for Coverage of Hospital Beds

A physician's prescription, and such additional documentation as the contractors' medical staffs may consider necessary, including medical records and physicians' reports, must establish the medical necessity for a hospital bed.

Patient Details Patient Name Patient Address Patient Phone (Work) Patient Phone (Home) Date of birth Social Security number Height Weight Diagnosis Codes (ICD-9) - List up to three

Physician Details Physician Name Physician Phone

Emergency Contact Emergency contact person Emergency contact phone

Insurance Information Primary Insurance Carrier Primary Insurance policy number/Medicare number Primary Insurance carrier phone number Secondary Insurance Carrier (if any) Secondary Insurance policy number/Medicare number Secondary Insurance carrier phone number

Questionnaire Do you require positioning of your body in ways not feasible in an ordinary bed? If yes, why? Do you require special attachments that cannot be fixed and used on an ordinary bed? If yes, what attachments?

Do you suffer from any of the following? Severe arthritis in lower extremities Severe cardiac conditions Spinal cord injury None of the above, my condition is:

Do you require frequent and/or immediate need for change in your body position? If yes, why? Does your condition require side rails? If yes, why?

Please understand that completing this form does not guarantee that you will be eligible for a hospital bed. We will review your answers and get back to you with our findings as soon as possible. Thank you for taking the time to complete this!

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