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): ɶ Requesting Physician ɶ Supplier
Client Information
Client Name:
Medicaid number:
Date of birth: / /
Supplier Information
Name: Telephone: Fax number:
Address:
TPI: NPI: Taxonomy: Benefit Code:
QRP name: QRP TPI: QRP NPI:
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: / /
DME/medical supplies provider representative name (Typed or Printed):
Prescribing Physician Information
Name: Telephone: Fax number:
Item
Number
HCPCS
Code
Description of
DME/medical supplies
Quantity Price
Prior
authorization
required?
Beyond
quantity
limit?
1
Custom
item?
1
1
ɶ Y ɶ N ɶ Y ɶ N ɶ Y ɶ N
2
ɶ Y ɶ N ɶ Y ɶ N ɶ Y ɶ N
3
ɶ Y ɶ N ɶ Y ɶ N ɶ Y ɶ N
4
ɶ Y ɶ N ɶ Y ɶ N ɶ Y ɶ 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.
Item
Number
2
(From
Section A)
Diagnosis 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. 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.
Date last seen by physician: / /
Duration of need for DME: ____________ month (s) Duration of need for supplies: ____________ month (s)
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: Date: / /
Signature stamps and date stamps are not acceptable
Prescribing physician’s license number:
Prescribing physician’s TPI: Prescribing physician’s NPI:
Effective Date_03172014 /Revised Date_06032014
1116 E Houston, San Antonio, TX 78205
