Get 866 534 5978

Filling out the Durable Medical Equipment (DME), Home Health & Home Infusion Referral Form online can simplify the process for obtaining necessary services. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully submit your form online.

1. Press the ‘Get Form’ button to access and open the form digitally.
2. Begin by filling in the member information section. Enter the first name, last name, Medicaid ID number, date of birth, home address, service address (if different), and phone number of the member. Ensure all required fields are completed, indicated by an asterisk (*).
3. Next, provide information for an alternative contact person, including their relationship to the member and their phone number.
4. Indicate the member's height in inches and weight in pounds.
5. Complete the requesting provider information section. Input the National Provider Identifier (NPI), Tax Identification Number (TIN), provider name, contact name, phone number, and fax number.
6. For the authorization request, check the box if the request relates to an inpatient discharge and input the discharge date and facility name, if applicable. Include the primary diagnosis code, start date of service, additional diagnosis code, end date of service, and the total number of units, visits, or days requested.
7. Select the requested services by checking the applicable boxes and providing additional information such as drug name, dosage, delivery device, hours of use, and frequency.
8. Fill in the durable medical equipment section by providing the HCPC code and description, along with any special considerations or additional information.
9. Lastly, the physician must sign and date the form, certifying that they are the treating physician identified in the document and that the services noted have been ordered.
10. After completing the form, review all entries for accuracy. Once confirmed, you can save your changes, download the document, print it, or share it accordingly.

Complete your 866 534 5978 form online today to ensure timely processing and access to necessary services.