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Respiratory Care

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care

The VitalCough® System Supplement Replacement Prescription Form

This order form is for The VitalCough® System Supplement Replacement only.  Please use the other prescription forms if you are ordering a different product.

Patient Information
*required field
 
 
 
Is the patient currently in the hospital?*

 
Patient Medicaid ID # is required for Medicaid beneficiaries in MA, MI, NJ, and NY
 
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
 
 
Number of Refills
 
 
Clinic Contact Information