Online Order/Rx Process

patient in the hospital

**Please note that the completed Order/Rx form is the only information required to initiate an order. The Terms Conditions and Responsibilities Form and documentation is necessary, but can be requested by Hill-Rom during the order process.

  1. The Vest® System Order/Rx Form

    If available, please complete all patient demographics, payer information, and health care facility information (a patient face sheet or demographic sheet attached is helpful).

  2. Terms Conditions and Responsibilities (Patient Consent Form)

    The patient is required to complete this form to give Hill-Rom/Advanced Respiratory the ability to use Protected Health Information (PHI) for treatment, payment, and communications with Insurance and Health Care Facilities. (If the patient is not available to sign, we will obtain this form directly from the patient).

  3. Medicare Criteria

    For Medicare patients, please review Medicare’s coverage criteria for The Vest® System and provide the patient’s medical records from the past year including Clinic Visits, Hospital Discharge Summaries, Chest CAT Scan reports, Medication Lists, and Pulmonary Function Test Results.

    OR

    Medical Necessity Checklist

    For Commercial Insurance/Medicaid patients, please complete this form. (Attaching the patient’s medical records is also helpful and may prevent Hill-Rom from requesting additional documentation related to the patient).

Custom order pads available for your convenience. Please contact Hill-Rom at 1-800-426-4224 and ask for an account services representative.