Download Our Prescription Forms
Everything providers need to send a referral to Comfort Compression
Download Ready to Wear Prescription Form
Blank fillable PDF for MD orders
Download Custom Prescription Form
Blank fillable PDF for MD orders
Download Mastectomy Prescription Form
Blank fillable PDF for MD orders
Referral Checklist
What we need to process an order
If the prescription isn’t signed when you send it to us, we’ll follow up with the referring MD to obtain the signature.
Qualifying LYMPHEDEMA Diagnoses (ICD-10)
| Code | Diagnosis |
|---|---|
| Q82.0 | Hereditary lymphedema |
| I89.0 | Lymphedema, not elsewhere classified |
| I97.2 | Postmastectomy lymphedema syndrome |
| I97.89 | Other postprocedural complications and disorders of the circulatory system, not elsewhere classified |
Qualifying Mastectomy Diagnoses (ICD-10)
| Code | Diagnosis |
|---|---|
| Z85.3 | Personal history of malignant neoplasm of breast |
| Z80.3 | Family history of malignant neoplasm of breast |
| C50.919 | Malignant neoplasm of unspecified site of unspecified female breast |
| C50.912 | Malignant neoplasm of unspecified site of left female breast |
| C50.911 | Malignant neoplasm of unspecified site of right female breast |
| Z90.12 | Acquired absence of left breast |
| Z90.11 | Acquired absence of right breast |
| Z90.13 | Acquired absence of bilateral breast |
A note on Medicare Advantage plans: Please don’t let network status dictate whether you send us Medicare Advantage patients. All MA plans except HMOs have out-of-network benefits, and we work with those routinely. We always verify coverage and let you and the patient know up front if costs differ meaningfully from in-network care.
How to Submit a Referral
Fax
866-984-3831
Questions?
Call us at 812-303-3831 — our staff can answer questions, help with garment selection, and walk you through the process.
What Happens After You Refer
- Benefits Verification: We verify insurance and contact the patient to notify them of any out-of-pocket or upfront costs.
- Patient Consents: We send the patient consents electronically (email or text).
- Order Placement: Once the patient approves, we place the order and ship directly to the patient.
- Communication: We notify you of any issues — insurance denials, difficulty reaching the patient, or backorder delays.
Turnaround Time: Approximately 10-14 business days. Delays can occur due to backordered products or difficulty reaching the patient for consents and payment.
Ready to Refer a Patient?
Get started by downloading the prescription form or sending us an email.