Get 8663256697

Filling out the 8663256697 form for durable medical equipment requests can be straightforward with proper guidance. This comprehensive guide will help you navigate each section of the form with ease, ensuring you provide all necessary information accurately.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to acquire the document and open it in the editor.
2. Begin by entering the member information. Fill in the member's name, member ID number, address, phone number, and date of birth. Additionally, list all relevant diagnosis codes (ICD-9/10).
3. Proceed to the physician and facility information section. Input the ordering physician's name, provider number, National Provider Identifier, Tennessee Medicaid Number, and contact details, including phone and fax numbers.
4. Complete the date of order or certificate of medical necessity. Document the treating or rendering provider's name, provider number, national provider identifier, Tennessee Medicaid number, address, contact name, phone number, and fax number.
5. Indicate whether the request is for purchase or rental, and provide the necessary HCPCS codes, any applicable modifiers, code descriptions, units requested, and the requested date of service.
6. If applicable, answer questions regarding recent surgeries related to the request and indicate if the member was discharged from a hospital facility.
7. Attach any required clinical information. Ensure you include medical records that support the request, such as clinical notes and lab results.
8. Once you have filled out all necessary fields and attached the appropriate documents, review the form for accuracy. You can then save changes, download, print, or share the form as needed.

Complete your documents online with confidence and make sure all necessary information is accurately provided.