Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to obtain the document and open it in your preferred editor.
2. Begin by completing the member information section. Provide the member's name, ID number, address, phone number, date of birth, and current diagnosis. Ensure that all details are accurate and complete.
3. In the physician and facility information section, fill in the ordering physician's name, provider number, national provider identifier, and Tennessee Medicaid number. Also, include the physician's phone and fax numbers, along with the date of the order or certificate of medical necessity.
4. Next, detail the treating or rendering provider's information by entering their name, provider number, national provider identifier, and Tennessee Medicaid number. Include the provider's address and contact details.
5. Indicate whether the request is for purchase or rental by checking the appropriate option. Fill in the HCPCS codes with any necessary modifiers, along with the code descriptions, units requested, date of service requested, and duration of the request.
6. Answer the questions regarding recent hospital discharge or surgery related to the request. If applicable, provide the discharge date.
7. Include clinical information if needed by attaching relevant records, lab results, and imaging results. Make sure to indicate if any photos are required and mail them to the specified address.
8. Once you have completed all sections, review the form for accuracy and completeness. Save, download, print, or share the document as necessary.

Complete your Bluecare Tn Phone Number form online today for efficient service requests.