Cervical Traction Device Form

* Required Information

Hours of Operation: Monday - Friday: 9am - 6pm Saturday: 10 am - 4:30pm Sunday: Closed
Phone Number: 720-532-8130 Fax Number: 720-328-8010 Email:pinnaclemedicalsupplies@yahoo.com

Client Name *

Client ID *

Medicare Cervical Traction Device Assessment Questionnaire

Please answer the following 2 questions and provide any additional notes.

1. Does the patient have a musculoskeletal or neurologic impairment traction equipment?

Yes

2. Has the appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device?

Yes

Additional Notes

IF THESE TWO ARE NOT MET, CERVICAL TRACTION WILL BE DENIED AS NOT A REASONABLE AND NECESSARY

Name of the person answering the questions, if other than physician

Name *

Title *

Signature*

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Employer *

Date

Physician's Signature*

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