Get Physician Order Form 2011-2024

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. Fax completed form to 1-512-514-4209. Section A Requested Durable Medical Equipment and Supplies This section was completed by check one Requesting Physician Supplier Client name Client date of birth / Is client under 21 years of age YES NO Client Medicaid number Supplier name Supplier address Supplier telephone Supplier Taxonomy Supplier Benefit Code QRP name QRP TPI Physician name Physician telephone Physician Fax 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 Item HCPCS Code Description of Quantity Number supplies Date 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. Check if additional documentation is attached as outlined in the TMPPM. Is the DME Provider Medicare certified YES NO If yes indicate Medicare number Section B Diagnosis and Medical Need Information This is a prescription for DME/supplies and must be filled out by the prescribing physician* From Section A ICD-9 Brief Diagnosis Descriptor Complete justification for determination of medical necessity for requested item s 2 Refer to Section A footnote 1. 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. If applicable include height/weight wound stage/dimensions and functional/mobility status in table below. Height Wound stage/dimensions Functionality/mobility status Note The Date last seen and Duration of need items below must be filled in* Date last seen by physician Duration of need for DME month s By signing this form I hereby attest that the information completed in Section A 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 Prescribing physician s license number Check if all of the information in Section A was complete at the time of the prescribing provider signature Effective Date07012011/Revised Date05312011. Fax completed form to 1-512-514-4209. Section A Requested Durable Medical Equipment and Supplies This section was completed by check one Requesting Physician Supplier Client name Client date of birth / Is client under 21 years of age YES NO Client Medicaid number Supplier name Supplier address Supplier telephone Supplier Taxonomy Supplier Benefit Code QRP name QRP TPI Physician name Physician telephone Physician Fax 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 Item HCPCS Code Description of Quantity Number supplies Date 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. Check if additional documentation is attached as outlined in the TMPPM. .