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Respiratory Care

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care

The Monarch® Airway Clearance System Prescription Form

This order form is for The Monarch® Airway Clearance System only.  Please use the other prescription forms if you are ordering a different product.  

Patient Information
*required field
 
Torso Measurement & Torso Length are both required if patient is under 15 years of age
 
Is the patient currently in the hospital?*

Patient Medicaid ID # is required for Medicaid beneficiaries in MA, MI, NJ, and NY
 
 
 
Protocol Information
 
Recommended Standard Protocol: Tx/Day: 2 | Minutes/Tx: 20 | Frequencies: 6-15Hz | Minimum usage/day: 10 minutes
 
Choose Standard or Custom Protocol*
 
For custom protocol, fill in the information below
 
 
 
Prescriber Information
 
Do not add space before or after Prescriber First Name, Last Name, or NPI Number.
 
 
Prescriber License # is required for prescribers in Pennsylvania
 
 
 
Clinic Information
 
 
 
 
Clinic Contact Information
 
 
 
Patient Documentation
 
This section provides the option to upload patient specific documentation often required for processing an order or submitting to a payer. Maximum file size is 16mb for each option below. Documentation can also be faxed to 800-870-8452.
 
 
 
 
 
 
Include the below documentation for BRONCHIECTASIS (BE) PATIENTS only