Get Mass Health Support Surface Form

This guide provides comprehensive instructions for completing the Mass Health Support Surface Form online. By following these steps, users can ensure that all necessary information is accurately captured for the medical necessity review.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Mass Health Support Surface Form and open it in your document editor.
2. Fill in the member's name as it appears on their MassHealth card in the designated field.
3. Enter the member’s MassHealth ID number, which can be found beside their name on the MassHealth card.
4. Type in the member’s date of birth using the month/day/year format.
5. Input the member's permanent legal address, including street address, town, and zip code.
6. Provide the primary diagnosis name and corresponding ICD-9-CM code that justifies the request for a support surface.
7. If applicable, enter the secondary diagnosis name and up to three ICD-9-CM codes related to additional medical conditions.
8. Indicate the types of wounds by checking all applicable options and describe any additional types not listed in the space provided.
9. For each wound, complete the wound description sections with all necessary details including location, dimensions, and characteristics.
10. Assess the functional status of the member by selecting the relevant options based on their mobility level.
11. Document the member’s mental status by checking all that are relevant, providing additional information if necessary.
12. Input the member's nutritional status details including height, weight, and any enteral supplements used.
13. Indicate the incontinence status by checking all applicable options and explaining any additional conditions.
14. List any drugs affecting wound healing, providing details about oral and topical medications as required.
15. Describe the wound care plan including nutritional intervention and specific treatments used.
16. Evaluate the outcomes of the treatment plan by marking the appropriate responses to each question.
17. Select the location where the support items will be used and specify any other relevant settings.
18. Provide the expected duration of the need for the support surface in number of days.
19. Choose the type of support surface(s) requested by checking all relevant items.
20. Describe the equipment requested clearly, including any specific features or accessories.
21. Fill in the information for the Durable Medical Equipment (DME) provider, including company name and contact details.
22. Enter the prescriber’s information, ensuring all contact details are accurate for follow-up.
23. If applicable, provide the details of the person completing the form on behalf of the prescriber.
24. Ensure that the prescriber signs the attestation, confirming the information's accuracy.
25. Review the completed form for any missing information before saving changes, downloading, printing, or sharing the document.

Complete your Mass Health Support Surface Form online today for efficient submission.