Get Blood Pressure Form

WeCare Pharmacy is the IEHP preferred provider. IEHP covers two different blood pressure monitors WeCare Pharmacy Foracare Test N GO Bluetooth Automatic Blood Pressure Monitor Features IEHP Telehealth program compatible Bluetooth connectivity Stores 200 of the most recent readings LCD Backlight Systolic Diastolic and pulse Oscilloscope measuring method automatic inflation Power Saving Automatic power off if system is idle for 3 minutes iFORA BP Download free from Apple Store and Google Play Store Adjustable cuff size Other IEHP Contracted Pharmacy Omron 5 series OR any other BPM machines with cost 65 Features of Omron 5 series NOT compatible with IEHP Telehealth program Dual settings for two users 100 readings memory storage with date and time stamp Wide range cuff that fits standard and large arms 9 to 17 inch circumference Compare patient s blood pressure level with the Blood Pressure Level Indicator Alert patient if the heart rate is irregular during reading Advanced averaging automatically displays the average of up to the last 3 readings taken within the last 10 minutes Member Information Please provide all Member information below to facilitate this request Date Name DOB IEHP ID Contact Phone Number Address Medical Justification Please choose one Suspected White Coat Hypertension o Office blood pressure 140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit. o At least two documented blood pressure measurements taken outside the office which are 140/90 mm Hg and o No evidence of end-organ damage Confirmed diagnosis of End Stage Renal Disease o On 3 or more HTN medications with history of uncontrolled blood pressure o Arrhythmia chronic heart failure heart valve problems previous history of stroke or stents. Other Please provide medical justification Please complete this form and fax it to Sig Use As Directed Quantity One 1 Cuff Size Signature Provider Name NPI Office Phone Office Fax. Blood Pressure Monitor Request Form In order to expedite the delivery of the Blood Pressure Monitor please fax this prescription to one of our contracted DME suppliers. WeCare Pharmacy is the IEHP preferred provider. IEHP covers two different blood pressure monitors WeCare Pharmacy Foracare Test N GO Bluetooth Automatic Blood Pressure Monitor Features IEHP Telehealth program compatible Bluetooth connectivity Stores 200 of the most recent readings LCD Backlight Systolic Diastolic and pulse Oscilloscope measuring method automatic inflation Power Saving Automatic power off if system is idle for 3 minutes iFORA BP Download free from Apple Store and Google Play Store Adjustable cuff size Other IEHP Contracted Pharmacy Omron 5 series OR any other BPM machines with cost 65 Features of Omron 5 series NOT compatible with IEHP Telehealth program Dual settings for two users 100 readings memory storage with date and time stamp Wide range cuff that fits standard and large arms 9 to 17 inch circumference Compare patient s blood pressure level with the Blood Pressure Level Indicator Alert patient if the heart rate is irregular during reading Advanced averaging automatically displays the average of up to the last 3 readings taken within the last 10 minutes Member Information Please provide all Member information below to facilitate this request Date Name DOB IEHP ID Contact Phone Number Address Medical Justification Please choose one Suspected White Coat Hypertension o Office blood pressure 140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit. o At least two documented blood pressure measurements taken outside the office which are 140/90 mm Hg and o No evidence of end-organ damage Confirmed diagnosis of End Stage Renal Disease o On 3 or more HTN medications with history of uncontrolled blood pressure o Arrhythmia chronic heart failure heart valve problems previous history of stroke or stents.