Get Dme Referral Request - Illinicare

Completing the DME Referral Request form for Illinicare is a crucial step in securing necessary durable medical equipment for members. This guide provides a clear and supportive approach to filling out the form accurately and efficiently.

Follow the steps to complete your DME referral request smoothly.

1. Click ‘Get Form’ button to obtain the DME Referral Request form and open it for editing.
2. Indicate whether the request is for rental or sale by circling the appropriate option on the form.
3. Fill in the date of the request in the specified field.
4. Provide the provider information, including the name or facility, tax identification number, fax number, contact person, and phone number.
5. Enter patient information related to the Illinicare member, including their name, social security number, date of birth, current address, and phone number. If the member is an infant, include the mother’s name and social security number.
6. If applicable, provide details for other insurance, including the name of the insurance provider, ID number, and the phone number.
7. List the diagnoses relevant to the DME request.
8. Fill in the ordering physician's name and contact phone number.
9. Specify the authorization start and end dates along with the previous authorization number if this request is a continuation.
10. Complete the equipment details by filling in the quantity per month, HCPC code, description of the equipment, whether it is for rental or sale, contract rate, and total costs.
11. Indicate who requested the form and insert the date next to the requester’s signature.
12. Once all sections are complete, review the form for accuracy, then save your changes, and proceed to download, print, or share the form as needed.

Complete your DME Referral Request online today to ensure timely approval and access to necessary equipment.