Order Form

Outpatient Phototherapy / Bilirubin Order Form

We appreciate your continued confidence in The Perfect Push.
For the most seamless experience, please submit referrals before 4 p.m.

For referrals placed after 4 p.m., a quick call to the office allows us to confirm nurse availability and prioritize same-day support whenever possible.

First and Last Name of Parent

Mother's Date of Birth

Infant Name

Infant's Date Of Birth

Sex

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Infant Weight

Gestational Age

Total/Direct Bilirubin Level

Date and Time of Collection

Pertinent Information

Insurance Carrier and Number (if available)

DATE BILIRUBIN NEEDED

Home Phototherapy Prescription

Enlighten Infant Home Care (EIHC) will provide home phototherapy for continuous use

Enlighten Infant Home Care (EIHC) will provide home phototherapy for continuous use using the Little Sparrows. bili-hut ™ or other device depending on equipment availability. EIHC RNs will provide parents with instruction on the use of the equipment.

*A daily nursing assessment with weight, vital signs and a STAT Neonatal Bilirubin T/D via heel stick will be performed daily while the baby is under our care and part of this service. Length of home care services will be evaluated daily by MD based on results.

OUTPATIENT BILIRUBIN ORDER

Enlighten Infant Home Care (EIHC) will provide skilled nursing assessment with weight, vital signs and a STAT Neonatal

Bilirubin level T/D via heel stick. Length of home care services will be evaluated daily based on results.

Diagnosis

Neonatal Jaundice, unspecified (P59.9)

ABO Isoimmunization of the Newborn (P55.1)

Signature

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Printed Name

Practice Name

Phone Number

Fax Number

NPI Number

Additional Contact Information for Results

Order Form

Outpatient Phototherapy / Bilirubin Order Form

Home Phototherapy Prescription

OUTPATIENT BILIRUBIN ORDER

Diagnosis

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