Get Durable Medical Equipment Authorization Request 2019-2026

Completing the Durable Medical Equipment Authorization Request form online can streamline the submission process and ensure that you provide all necessary information. This guide will walk you through each section of the form, ensuring that you understand what is required to submit your request successfully.

Follow the steps to complete the authorization request online.

1. Press the ‘Get Form’ button to download the form, and open it in your preferred document editor.
2. In Part A, provide your requestor information. Select whether this is an initial request or a correction, enter the original authorization number if applicable, the date of the request, your name, and your phone number. Ensure all fields are completed.
3. In Part B, enter the claimant’s details, including their case ID, date of birth, first name, last name, and date of injury. All fields are required for proper identification.
4. In Part C, input the provider’s information. Include the OWCP provider ID, tax ID, name, and fax number. Indicate if you are providing care for a family member and specify the relationship if applicable.
5. In Part D, list the service line information. Specify the body part needing treatment, enter the diagnosis codes, and fill in the service dates along with the diagnosis pointers. Also, provide the procedure codes, body part modifiers, units requested, and whether the equipment is for rental or purchase, including the total cost.
6. In Part E, attach all supporting documents required for the request, such as a prescription and treatment plan. Remember to include the claimant ID on each page.
7. Once all sections are complete, review your entries for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your Durable Medical Equipment Authorization Request online today!