<% Session.Timeout = 120 Response.AddHeader "P3P", "CP=CAO PSA OUR" dim pw : pw = "waiver" dim msg : msg = "" IF LEN(request("password")) > 0 THEN If LCASE(request.form("password")) = pw THEN Session("access") = true Session("formType") = Null ELSE Session("access") = false Session("formType") = Null msg = "Password incorrect. If you continue to have problems please contact Grandiff Medical" END IF END IF If LEN(request("btnRockville")) > 0 THEN Session("formType") = "Rockville" showIt = True END IF IF LEN(request("btnSilverSpring")) > 0 THEN Session("formType") = "SilverSpring" showIt = True END IF %>

<% IF session("access") = true AND NOT IsNull(session("formType")) THEN %> <% IF Session("formType") = "Rockville" THEN %> <% ELSE %> <% END IF %>

GRANDIFF MEDICAL SUPPLIES
11631 NEBEL STREET
ROCKVILLE, MD 20852
Phone: (301) 816-9100 Fax: (301) 816-0003

DME REFERRAL FORM

GRANDIFF MEDICAL SUPPLIES
20 Vital Way
Silver Spring, MD 20904
Phone: 301-388-0596 Fax: 301-388-0597

DME REFERRAL FORM

Date:

Patient:

Gender: Male Female

Address

Next of Kin:
Phone:

Phone Number:

Weight: Ht: DOB:

Physician:

Address:

Medicare #

Other Insurance Company:

Phone:
Fax:

Other Insurance ID #

Diagnosis (ICD9) Codes:

If Pt. has wound, No. of wound Sites:

Case Worker: Phone:

Product #	Size	Unit Ordered	Item Description

Comments

<% ElseIf Session("access") = True AND IsNull(Session("formType")) THEN %>

Please Choose your Location:

<% Else %>

Grandiff Medical Supplies - Order Form Login

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<% END IF %>