Zing Portable Size 1 Configurator Page Standing Device Letter of Medical NecessityConsumer InformationStander Evaluation Date Date Format: MM slash DD slash YYYY Payor InformationPlease list payment source.Consumer Insurance ID:Consumer Name First Last Consumer Date of Birth Date Format: MM slash DD slash YYYY GenderFemaleMaleWeight (pounds)Height (inches)Please enter a number from 10 to 82.Primary DiagnosisSpinal Cord Injury (SCI)Cerebral PalsyMuscular DystrophyTraumatic Brain Injury (TBI)Multiple Sclerosis (MS)Amyotrophic Lateral Sclerosis (ALS)Spinal Muscular Atrophy (SMA)Spina BifidaStrokeRett syndromeEpilepsyotherPlease describe primary diagnosis*Primary Diagnosis Date of Onset Date Format: MM slash DD slash YYYY Secondary Diagnosis(s)Treatment Diagnosis(s)Writer's Expert CredentialsClinician Name First Last TitleCertifications/LicensurePTDPTATPCRTSSMSMDOTR/LOtherHold down "Ctrl" key and click all that applyOther credentialsEmail* PhoneAreas of PracticePediatricAdultGeriatricHold down "Ctrl" key and click all that applySpecific Pediatric Areas of PracticeEarly InterventionBirth to 3-years-oldBirth to 5-years-oldBirth to 21-years-oldSchool-age, ElementarySchool-age, Middle SchoolSchool-age, High SchoolPrivate PracticeIn-patient rehabilitationOut-patient rehabilitationHold down "Ctrl" key and click all that applySpecific Adult Areas of PracticePrivate PracticeIn-patient rehabilitationOut-patient rehabilitationHold down "Ctrl" key and click all that applySpecific Geriatric Areas of PracticeIn-patient rehabilitationOut-patient rehabilitationPrivate PracticeSkilled Nursing FacilityHold down "Ctrl" key and click all that applyOrganizationPlease list your current employer or facility.Statement Establishing Expert CredentialsPlease provide a short statement that summarizes your educational and clinical experiences which prove competancy in your area(s) of practice.History and Physical ExamSummary of Medical ConditionShare relevant details of patient's medical history.PrognosisProvide a description of the patient's prognosis and if they do not start or continue a standing program - how would that affect it?Co-morbid conditionsChief complaints/presenting problemsPatient was evaluated for a standing program and determined appropriate because.....(should tie together medical history, prognosis, co-morbid conditions and make clear potential negative outcomes if standing program does not start or continue)Physical AssessmentDiscuss your patient's current physical status and connect the current status to patient need, risk/mitigation concerns in the subsequent field. Address only the areas specific to your individual patient needs.Physical assessment Strength Range of motion Tone/Spasticity Skin Integrity Bowel Bladder/Urinary Sensation Pain Respiratory other Discuss Strength issuesDiscuss how standing programs will impact Strength & related issuesDiscuss Range of Motion issuesDiscuss how standing will impact Range of Motion & related issuesDiscuss Tone/Spasticity issuesDiscuss how standing will impact Tone/Spasticity issuesDiscuss Skin Integrity issuesDiscuss how standing will impact Skin Integrity issuesDiscuss Bowel issuesDiscuss how standing will impact Bowel issuesBladder/UrinaryDiscuss how standing will impact Bladder/Urinary issuesSensationDiscuss how standing will impact Sensation & related issuesPainDiscuss how standing will impact Pain & related issuesRespiratoryDiscuss how standing will impact Respiratory issuesDiscuss other physical issuesDiscuss how standing will impact other physical issuesFunctional StatusDiscuss patient's CURRENT functional status and the effect a standing program may have on each area (discuss only those that apply to your individual patient).Functional Status Cognitive level Communication Feeding Respiratory Balance ADLs/IADLs Other Discuss Cognitive LevelDiscuss how standing will impact Cognitive LevelDiscuss Communication statusDiscuss how standing will impact Communication statusDiscuss Feeding functional statusDiscuss how standing will impact Feeding functional statusDiscuss Respiratory statusDiscuss how standing will impact Respiratory statusDiscuss BalanceDiscuss how standing will impact BalanceDiscuss ADLs/IADLsDiscuss how standing will impact ADLs/IADLsDiscuss other functional status issuesDiscuss how standing will impact other functional status issuesStanding Program GoalsDiscuss those physical and functional statuses that pertain to the patient's need for a standing deviceOutline the Standing program goal(s)Documentation of Other Standing Devices ConsideredDiscuss what other devices were considered for the patient and why each was NOT appropriate or the best choice.Standing Devices Considered One Position Multi-position Sit to stand Mobile stander Manual wheelchair/standing system Power wheelchair/standing system One Position Stander*A one position upright or prone only stander would not allow patients to rest between short bursts of upright or prone standing as is necessary to build head control. A supine only stander would not provide the option of prone positioning to work on head control. Multi-position Stander*Multi-position stander will not provide adequate positioning capabilities to address Range of Motion (ROM) concerns.Sit to Stand Stander*Mobile Stander*Manual Or Power Wheelchair/Standing System*Documentation of Trialed Devices and OutcomesProvide documentation of the device(s) trialed. *This section is specific to the trial - not the selected device, although in some cases they may be the same. The next section walks you through documentation of the selected standing device.Date of Trial Date Format: MM slash DD slash YYYY Make/Model Device TrialedPA5520 Zing MPS Size 1PA5520TT Zing MPS TT Size 1PA5522 Zing Supine Size 1PA5522 Zing Supine TT Size 1PA5524 Zing Vertical Size 1PA5522 Zing Prone Size 1PB5500 Zing MPS Size 2PB5502 Zing Supine Size 2PB5562 Zing MPS TT Size 2PB5564 Zing Supine TT Size 2PB5606 Zing Prone Size 2PT50001 Bantam Extra SmallPT50002 Bantam SmallPY5500 Bantam MediumPNG50162 Evolv MediumPNG50084 Evolv LargePNG50209 Evolv XTPNG50410 E3 MediumPNG50400 E3 LargePNG50187 Glider MediumPNG50024 Glider LargeP2100 StrapStandP2000 StrapStand ClassicOtherIf other, please specify*Evidence Patient Demonstrated Ability to Safely Use DeviceEvidence Patient Maintained Medical Stability throughout TrialDocumentation the Patient's Environment can Accommodate the DeviceUpload Relevant Documents to Standing Device Trial Drop files here or Accepted file types: jpg, jpeg, gif, png, bmp, tif, tiff, ico, txt, csv, tsv, rtf, pdf, zip, doc, ppt, xls, docx, xlsx, pptx, odt, odp, ods, key, numbers, pages. i.e Range of Motion Chart (ROM), standing progress log, picture(s) of patient using standing device, documentation that home/environment will accommodate standing deviceAdditional Trial(s) Trial 2 Trial 3 Date of Trial 2 Date Format: MM slash DD slash YYYY Make/Model of 2nd Device TrialedPA5520 Zing MPS Size 1PA5520TT Zing MPS TT Size 1PA5522 Zing Supine Size 1PA5522 Zing Supine TT Size 1PA5524 Zing Vertical Size 1PA5522 Zing Prone Size 1PB5500 Zing MPS Size 2PB5502 Zing Supine Size 2PB5562 Zing MPS TT Size 2PB5564 Zing Supine TT Size 2PB5606 Zing Prone Size 2PT50001 Bantam Extra SmallPT50002 Bantam SmallPY5500 Bantam MediumPNG50162 Evolv MediumPNG50084 Evolv LargePNG50209 Evolv XTPNG50410 E3 MediumPNG50400 E3 LargePNG50187 Glider MediumPNG50024 Glider LargeP2100 StrapStandP2000 StrapStand ClassicOtherEvidence Patient Demonstrated Ability to Safely Use Device - Trial 2Evidence Patient Maintained Medical Stability throughout 2nd TrialDocumentation the Patient's Environment can Accommodate the Device - Trial 2Upload Relevant Documents to Standing Device Trial 2 Drop files here or Accepted file types: jpg, jpeg, gif, png, bmp, tif, tiff, ico, txt, csv, tsv, rtf, pdf, zip, doc, ppt, xls, docx, xlsx, pptx, odt, odp, ods, key, numbers, pages. i.e Range of Motion Chart (ROM), standing progress log, picture(s) of patient using standing device, documentation that home/environment will accommodate standing deviceDate of Trial 3 Date Format: MM slash DD slash YYYY Make/Model of 3rd Device TrialedPA5520 Zing MPS Size 1PA5520TT Zing MPS TT Size 1PA5522 Zing Supine Size 1PA5522 Zing Supine TT Size 1PA5524 Zing Vertical Size 1PA5522 Zing Prone Size 1PB5500 Zing MPS Size 2PB5502 Zing Supine Size 2PB5562 Zing MPS TT Size 2PB5564 Zing Supine TT Size 2PB5606 Zing Prone Size 2PT50001 Bantam Extra SmallPT50002 Bantam SmallPY5500 Bantam MediumPNG50162 Evolv MediumPNG50084 Evolv LargePNG50209 Evolv XTPNG50410 E3 MediumPNG50400 E3 LargePNG50187 Glider MediumPNG50024 Glider LargeP2100 StrapStandP2000 StrapStand ClassicOtherEvidence Patient Demonstrated Ability to Safely Use Device - Trial 3Evidence Patient Maintained Medical Stability throughout 3rd TrialDocumentation the Patient's Environment can Accommodate the Device - Trial 3Upload Relevant Documents to Standing Device Trial 3 Drop files here or Accepted file types: jpg, jpeg, gif, png, bmp, tif, tiff, ico, txt, csv, tsv, rtf, pdf, zip, doc, ppt, xls, docx, xlsx, pptx, odt, odp, ods, key, numbers, pages. i.e Range of Motion Chart (ROM), standing progress log, picture(s) of patient using standing device, documentation that home/environment will accommodate standing deviceJustification of the Selected DeviceJustification of the model and each necessary support and positioning component.Make/Model Device SelectedPA5520 Zing MPS Size 1PA5520TT Zing MPS TT Size 1PA5522 Zing Supine Size 1PA5522 Zing Supine TT Size 1PA5524 Zing Vertical Size 1PA5522 Zing Prone Size 1PB5500 Zing MPS Size 2PB5502 Zing Supine Size 2PB5562 Zing MPS TT Size 2PB5564 Zing Supine TT Size 2PB5606 Zing Prone Size 2PT50001 Bantam Extra SmallPT50002 Bantam SmallPY5500 Bantam MediumPNG50162 Evolv MediumPNG50084 Evolv LargePNG50209 Evolv XTPNG50410 E3 MediumPNG50400 E3 LargePNG50187 Glider MediumPNG50024 Glider LargeP2100 StrapStandP2000 StrapStand ClassicTransfer ConsiderationsEvidence patient is able to use selected deviceGrowth ConsiderationsNecessary Support & Positioning ComponentsThe necessary support and positioning components, as well as medical justification for each, automatically inserted here in the completed LMN.PLACE APPROPRIATE FIELDS HERE!DELETE ME TO BEGIN BUILDING PRODUCT CONFIGURATOROutline of Prescribed Standing Program RecommendationsRecommended Standing ProgramPatient will be using the stander on a daily basis, beginning with 30 minutes, 2x/day at 10 degrees of abduction; increasing to 30 degrees of hip abduction, a minimum of 2x/day for 30 minutes. Patient is currently in foster care and the carryover with standing program is excellent with 60-90 minutes of standing a day.Applicable ResearchThese citations will appear directly under the Standing Program Goals and Outline of Prescribed Standing Program Recommendations sections in the generated letter.Cite any applicable research or additional justification for the standing program Macias-Merlo L, Bagur-Calafat C, Girabent-Farrés M, A Stuberg W., “Effects of the standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy.” Disabil Rehabil. 2016 Jun;38(11):1075-81. Epub 2015 Oct 30.
Justify ItJustify It