Get Letter Of Intent Loi-dme (pdf) - Mass.gov - Mass

This guide provides a comprehensive overview and step-by-step instructions for filling out the Letter of Intent for Durable Medical Equipment and Supplies (LOI-DME) form required by MassHealth. A clear understanding of this form is essential for those looking to enroll as a MassHealth provider or requesting a DME specialty.

Follow the steps to complete the LOI-DME form accurately.

1. Press the ‘Get Form’ button to access the LOI-DME form and open it within a suitable document viewer or editor.
2. Begin filling out the form by entering your applicant's tax ID number in the provided field.
3. Complete the legal entity name field with the full registered name of your organization.
4. Fill in the legal entity address section with the complete address of your organization.
5. If you have a ‘Doing Business As’ (DBA) name, enter it in the appropriate field.
6. Provide the DBA address, which should correspond to the service facility address.
7. List the contact person's name, ensuring that it is someone available for communication regarding the application.
8. Enter the contact person's email address clearly.
9. Fill in the contact person's phone number for any necessary follow-up.
10. If applicable, provide the fax number for correspondence.
11. If currently enrolled in MassHealth, list all your MassHealth provider ID numbers.
12. Indicate the primary scope of your organization’s business, such as mobility equipment and accessories.
13. Answer whether your organization holds a pharmacy license, and if so, provide the license number.
14. Detail the specific DME services, equipment, and medical supplies intended for MassHealth members.
15. List the address for each service facility location operated by your organization.
16. Specify the service facility DBA address that this LOI pertains to.
17. Describe the geographical areas where the services will be provided.
18. Indicate whether you plan to use subcontractors for any of the services.
19. If subcontractors will be used, provide their names and addresses, along with the services or supplies they will provide. If not, indicate N/A.
20. List any existing contracts with other third-party payers and note the requirement to update MassHealth on any changes.
21. Review the attestation section carefully, sign the form, and ensure that the signature is from the appropriate individual.
22. Complete the printed legal name, title of the signatory, and their contact information.
23. Finally, write the date of signing and make sure all information is accurate and complete before submission. Save changes to the document, and optionally download, print, or share the completed form.

Start filling out your LOI-DME form online today to ensure a smooth application process.