Get Durable Medical Equipment Authorization Request Form

Filling out the Durable Medical Equipment Authorization Request Form online is a crucial step for obtaining necessary medical equipment. This guide provides clear instructions to help users navigate the form efficiently and accurately.

Follow the steps to complete your authorization request online.

1. Click ‘Get Form’ button to obtain the Durable Medical Equipment Authorization Request Form and open it in your preferred editor.
2. Enter the date requested in the designated field to indicate when the authorization is being requested.
3. In the 'Requested by' section, provide the name of the individual or organization submitting the request.
4. Fill in the case file number to ensure proper tracking of the authorization request.
5. In the 'Claimant Name' field, enter the name of the person who will be using the durable medical equipment.
6. Optionally, include the claimant's date of birth to assist in identifying the person within the system.
7. Provide the provider's name and the ACS provider number in the next two fields.
8. Fill in the provider's tax identification number, which is necessary for billing purposes.
9. In the 'Date(s) of Service Requested' section, specify when the requested equipment is needed.
10. Input the relevant procedure code or modifier(s) in the designated area to identify the equipment required.
11. Indicate whether the equipment is to be rented or purchased, along with the price per item.
12. In the 'Duration Requested' field, state how long the equipment will be needed.
13. Use the comments section to provide any additional information or special instructions related to the equipment request.
14. After completing all fields, save your changes, and choose to download, print, or share the form as needed.

Complete your Durable Medical Equipment Authorization Request Form online today to ensure prompt processing of your request.