Home Health Services (Title XIX) DME
Client/Patient Information
Client/Patient Name
*
Client/Patient Medicaid Number
*
Client/Patient Date of Birth
*
/
Month
/
Day
Year
Date
Requesting Physician or Allowed Practitioner Information
Name
*
Telephone
*
Fax
*
Medical equipment/supplies needed
Select the items you would like to prescribe.
Item #1
*
Please Select
E0603
A6530
A4670
E0603 = Breast Pump, A6530 = Compression, A4670 = Automatic Blood Pressure Monitor
Description of DME
*
Quantity
*
Please Select
1
2
4
6
8
Breast Pump and Blood Pressure Monitor should only be qty = 1, Compression socks can be 2, 4, 6, or 8 depending on need.
Item #1 Diagnosis Code
*
Please Select
Z39.1
R60.9
O22.0
O13.9
R03.0
I10
Z39.1 = Breastfeeding Mother | R60.9 = Edema | O22.0 = Varicose veins | O13.9 = Gestational hypertension | R03.0 Elevated BP reading | I10 = Primary hypertension
Brief Diagnosis Description
*
Item #2 Information if needed:
Item #2
Please Select
A4670
A6530
E0603
Description of DME
Quantity
Please Select
1
2
4
6
8
Item #2 Diagnosis Code
Please Select
Z39.1
R60.9
O22.0
O13.9
R03.0
I10
Diagnosis Description
End
Item #3 information if needed:
Item #3
Please Select
A4670
A6530
E0603
Description of DME
Quantity
Please Select
2
4
6
8
Item #3 Diagnosis Code
Please Select
Z39.1
R60.9
O22.0
O13.9
R03.0
I10
Diagnosis Description
End
Item #4 information if needed:
Item #4
Please Select
A4670
A6530
E0603
Description of DME
Quantity
Please Select
1
2
4
6
8
Item #4 Diagnosis Code
Please Select
Z39.1
R60.9
O22.0
O13.9
R03.0
I10
Diagnosis Description
End
Duration of need for DME:
*
Please Select
99
1
2
3
4
5
6
7
8
9
10
11
Select 99 for lifetime as these are all purchase items.
By signing this form, I hereby attest that the information in Section “A”, with the exception of the rendering 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 Requesting Physician or Allowed Practitioner:
*
Date
*
/
Month
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Day
Year
Date
NPI
*
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Rendering Provider Information
I certify that the services being supplied under this order are consistent with the physician or allowed practitioner’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. Rendering Provider’s Signature:
Date
/
Month
/
Day
Year
Date
Rendering Provider Name
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