Get Updated - Durable Medical Equipment Form

Completing the Updated - Durable Medical Equipment Form online can be a straightforward process when you understand each section and its requirements. This guide provides step-by-step instructions to help ensure your submission is accurate and complete.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form. Once opened, familiarize yourself with the layout and required information.
2. Enter the date requested in the designated field. This indicates when the authorization request is being submitted.
3. Fill in the name of the individual submitting the request under 'Requested by' and provide a phone number for any follow-up communication.
4. Input the claimant's full name, date of birth, and date of injury in the respective fields to help identify the person requiring durable medical equipment.
5. Enter the provider's name, ACS provider number, and tax ID number. This information verifies the medical provider submitting the request.
6. Indicate whether the provider is in the process of enrolling by selecting 'Yes' or 'No'.
7. Complete the procedure code information. You may input up to five CPT/HCPCS codes, providing the date of service range and whether the equipment is for rental or purchase.
8. For each procedure code, specify the number of units or days requested and the total price per item.
9. In the treatment plan section, detail the specific body parts being treated and include the ICD-9 diagnosis code(s).
10. Determine if the request involves an implant by indicating 'Y' or 'N'. If applicable, provide the total cost and units requested for the implant.
11. Include any comments or additional information that may support the authorization request.
12. Review all entries for accuracy. Once completed, users can save the changes, download the form, print, or share it as necessary.

Start filling out the Updated - Durable Medical Equipment Form online today to simplify your authorization request process.