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Get Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form 2014-2024

Home Health Services Title XIX DME/Medical Supplies Physician Order Form See instructions for completing Title XIX Home Health Durable 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 Requesting Physician Supplier Client Information Date of birth Medicaid number Client Name / Supplier Information Name Telephone Fax number Address TPI NPI Taxonomy QRP TPI QRP name Benefit Code I certify that the services being supplied under this order are consistent with the physician s determination of medical necessity and prescription* The prescribed items are appropriate and can safely be used in the client s home when used as prescribed* DME/medical supplies provider representative signature Date Prescribing Physician Information Item Number HCPCS Code Description of Quantity Price Prior authorization required Beyond limit 1 Custom item 1 Y N 1. If Yes additional documentation must be provided to support determination of medical necessity. Section B Diagnosis and Medical Need Information This is a prescription for DME/supplies and must be filled out by the prescribing physician* Diagnosis Brief Diagnosis Descriptor Complete justification for determination of medical necessity for requested item s 2 Refer to Section A footnote 1 From Section A 2. Each item requested in Section A must have a correlating diagnosis and medical necessity justification* Enter all Item numbers from the table in Section A that pertain to each diagnosis. A range of item numbers may be entered* If applicable include height/weight wound stage/dimensions and functional/mobility status Note The Date last seen and Duration of need items must be filled in* Duration of need for DME month s Date last seen by physician By signing this form I hereby attest that the information in Section A with the exception of the DME provider s signature was complete at the time of my signature and is consistent with the determination of the client s current medical necessity and prescription* By prescribing the identified DME and/or medical supplies I certify the prescribed items are appropriate and can safely be used in the client s home when used as prescribed* Signature and attestation of prescribing physician Signature stamps and date stamps are not acceptable Effective Date03172014 /Revised Date06032014. Section A Requested Durable Medical Equipment and Supplies This section was completed by check one Requesting Physician Supplier Client Information Date of birth Medicaid number Client Name / Supplier Information Name Telephone Fax number Address TPI NPI Taxonomy QRP TPI QRP name Benefit Code I certify that the services being supplied under this order are consistent with the physician s determination of medical necessity and prescription* The prescribed items are appropriate and can safely be used in the client s home when used as prescribed* DME/medical supplies provider representative signature Date Prescribing Physician Information Item Number HCPCS Code Description of Quantity Price Prior authorization required Beyond limit 1 Custom item 1 Y N 1. If Yes additional documentation must be provided to support determination of medical necessity. Section B Diagnosis and Medical Need Information This is a prescription for DME/supplies and must be filled out by the prescribing physician* Diagnosis Brief Diagnosis Descriptor Complete justification for determination of medical necessity for requested item s 2 Refer to Section A footnote 1 From Section A 2. .

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