Get Addendum To Home Health Title Xix Order Form

The Addendum To Home Health Title XIX Order Form allows for the request of durable medical equipment and supplies for clients under Medicaid. This guide provides clear instructions for filling out the form online, ensuring an efficient and accurate submission.

Follow the steps to complete the Addendum To Home Health Title XIX Order Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select whether the section A is completed by the requesting physician or the supplier by checking the appropriate box.
3. Fill in the client information, including the date of birth, Medicaid number, and client name.
4. Provide the supplier information, including their name, telephone number, fax number, address, TPI, NPI, taxonomy, QRP name, benefit code, QRP TPI, and QRP NPI.
5. Affirm the certification statement regarding medical necessity and the use of prescribed items in the client’s home by having the DME provider representative sign and date the form.
6. In the 'Prescribing Physician Information' section, complete their name, item number, telephone number, HCPCS code, fax number, and quantity for each requested durable medical equipment and supplies.
7. Indicate price and whether prior authorization is required for each item and whether it exceeds quantity limits or is custom by checking 'Yes' or 'No' where applicable.
8. Ensure that the prescribing physician attests to the accuracy of the information provided by signing and dating the form.
9. Fill in the prescribing physician’s license number, TPI, and NPI as required.
10. Finally, review all entered information for accuracy before saving changes. You may then download, print, or share the completed form.

Start filling out your Addendum To Home Health Title XIX Order Form online today for a smooth submission process.