Get Title Xix Physician Order Form For Tens Unit - Hope Medical Supply

Filling out the Title XIX Physician Order Form For TENS Unit is an essential step in ensuring that users receive the necessary medical equipment and supplies. This comprehensive guide will walk you through each section of the form, providing clear instructions for completing it correctly online.

Follow the steps to effectively complete the online form.

1. Click the ‘Get Form’ button to obtain the Title XIX Physician Order Form and open it for editing.
2. In Section A, you will select who completed this section by checking the box next to ‘Requesting Physician’ or ‘Supplier’. Fill in the client information, including the date of birth, Medicaid number, and client name.
3. Next, provide the supplier information. Input the name (Hope Medical Supply), telephone number, fax number, address, Taxpayer Identification Number (TPI), National Provider Identifier (NPI), and taxonomy code.
4. Certify the order by ensuring you include the signature of the DME provider representative and the date next to their printed name.
5. Move to the 'Prescribing Physician Information' section. Fill out the physician's name, telephone number, and fax number.
6. In Table 1, list the item number, the HCPCS code, description of the DME/medical supplies, and the quantity needed.
7. For each item, specify if prior authorization is required, if it exceeds the quantity limit, or if it is a custom item by checking 'Yes' or 'No'.
8. Proceed to Section B and fill in the diagnosis and medical need information. For each item listed in Section A, provide a correlating diagnosis and justification for medical necessity.
9. Include additional details such as height/weight, wound stage/dimensions, and functional/mobility status if applicable. Make sure to fill in 'Date last seen' and 'Duration of need' for both DME and supplies.
10. Finally, the prescribing physician must sign and date the form, ensuring that they do not use signature stamps, and include their license number, TPI, and NPI.
11. Once all sections are completed, save your changes, download the form, print it, or share it according to your needs.

Take action now and complete your documents online for efficient processing.