Follow the steps to complete the DME Prior Authorization Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the date at the top of the form, followed by the contact person's name, phone number, and fax number. Ensure that each field marked with an asterisk (*) is completed, as incomplete forms will be returned without processing.
3. Next, provide the ordering provider's details, including their name and phone number. Enter the vendor name, member name, date of birth, and Trillium Medicare ID number accurately.
4. Indicate the member's sex by checking the appropriate box. If there is an urgent need, include the member's phone number and relevant clinical documentation to support the request.
5. Fill in the Trillium Medicaid ID number, and choose one of the options for the request type: SNF discharge, Workers Comp, or accident/injury related. Complete any applicable fields about the service's recent history.
6. Proceed to the diagnosis section. Fill out ICD9 codes and their descriptions for the member's condition, ensuring each code corresponds accurately to the diagnoses being claimed.
7. For each item you are requesting authorization for, enter the item description, HCPCS code, and any necessary modifications (mods). Specify whether the items are for rent or purchase and the required time frame for delivery in days or weeks.
8. Continue to enter additional items as needed, always repeating the same information: item description, HCPCS code, quantity, etc. Ensure total quantities and related information are accurately summarized.
9. After you have entered all items, check the total costs, units per package, and their respective prices. This section is critical for ensuring the request reflects accurate and clear information for processing.
10. Finally, review the form thoroughly for any missing information. Save changes, download, print, or share the completed form as required.

Complete your DME Prior Authorization Form online today to ensure your request is processed smoothly.