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Get TX TMHP F00030 2016-2024

Rable Medical Equipment (DME)/Medical Supplies Physician Order Form. This order form cannot be accepted beyond 90 days from the date of the physician's signature. Section A: Requested Durable Medical Equipment and Supplies This section was completed by (check one): â–¡ Requesting Physician â–¡ Supplier Client Information Medicaid number: Client Name: Date of birth: Supplier Information Name: Telephone: Fax number: Address: TPI: NPI: QRP name: Taxonomy: Benefit Code: QRP TPI: QRP NP.

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