Get Pt Report Sample

The Pt Report Sample is an essential document for submitting requests for durable medical equipment. Completing the form accurately and thoroughly is crucial for ensuring prompt processing and approval of services.

Follow the steps to fill out the Pt Report Sample online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the Fidelis Care member's name, including their last name, first name, and middle initial in the designated field.
3. Provide the patient's member ID number, ensuring it is entered correctly to prevent delays.
4. Enter the patient's date of birth in the specified format (mm/dd/yyyy).
5. In the provider information section, fill in the address details, including city, state, and zip code. Ensure the information is clear and legible.
6. Include the provider's phone number with the area code and their tax identification number (Tax ID).
7. Fill in the provider's National Provider Identifier (NPI) number and fax number, ensuring all details are accurate.
8. Specify the ordering doctor's name and their corresponding NPI.
9. Complete the address and phone number fields for the ordering doctor, ensuring they are filled in completely.
10. If applicable, indicate the IPA affiliation of the provider.
11. In the DME services section, list the durable medical equipment required, along with the relevant ICD-9 codes and CPT/HCPCS codes with their descriptions.
12. Specify the quantity of the requested durable medical equipment.
13. After filling out all required fields, review the form for accuracy and completeness.
14. Once you are satisfied with the information provided, save the changes, download, print, or share the form as necessary.

Complete your Pt Report Sample online today for efficient processing of your request.