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Get Mdwise Dme Auth Form

DME/ORTHOTICS/PROSTHETICS PRIOR AUTHORIZATION REQUEST IF NOT COMPLETED IN FULL REQUEST WILL BE RETURNED Phone 888-961-3100 Fax 888-465-5581 Your request MUST include Physician s Order and Documentation of Medical Necessity Hx Previous Tx Consult evals Rehab Evals and Tests to be processed. MEDICAL EQUIPMENT REQUESTS Member Name Last First THIS BOX FOR MDwise Hoosier Alliance USE ONLY Middle Form Received / / DOB / / Ph Guardian if applies Case M....

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