F00030 Page 1 of 2 Revised Date: 02/01/2016 | Effective Date: 04/01/2016
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.
Prior Authorization Request Submitter Certification Statement
I certify and affirm that I am either the Provider, or have been specifically authorized by the Provider (hereinafter
"Prior Authorization Request Submitter") to submit this prior authorization request.
The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are
personally acquainted with the information supplied on the prior authorization form and any attachments or
accompanying information and that it constitutes true, correct, complete and accurate information; does not
contain any misrepresentations; and does not fail to include any information that might be deemed relevant or
pertinent to the decision on which a prior authorization for payment would be made.
The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the
information supplied on the prior authorization form and any attachments or accompanying information was
made by a person with knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the
ordinary course of business of the Provider; is the original or an exact duplicate of the original; and is maintained
in the individual patient's medical record in accordance with the Texas Medicaid Provider Procedures Manual
(TMPPM).
The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that
prior authorization is a condition of reimbursement and is not a guarantee of payment.
The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior
authorization will be from Federal and State funds, and that any false claims, statements or documents,
concealment of a material fact, or omitting relevant or pertinent information may constitute fraud and may be
prosecuted under applicable federal and/or State laws. The Provider and Prior Authorization Request Submitter
understand and agree that failure to provide true and accurate information, omit information, or provide notice
of changes to the information previously provided may result in termination of the provider’s Medicaid
enrollment and/or personal exclusion from Texas Medicaid.
The Provider and Prior Authorization Request Submitter certify, affirm and agree that by checking "We Agree"
that they have read and understand the Prior Authorization Agreement requirements as stated in the relevant
Texas Medicaid Provider Procedures Manual and they agree and consent to the Certification above and to the
Texas Medicaid & Healthcare Partnership (TMHP) Terms and Conditions.
We Agree
F00030 Page 2 of 2 Revised Date: 02/01/2016 | Effective Date: 04/01/2016
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
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
Qty. Price
Prior
authorization
required?
Beyond
quantity
limit?
1
Custom
item?
1
1
Y N Y N Y N
2
Y N Y N Y N
3
Y N Y N Y N
4
Y N Y N 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.
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 TPI: NPI: License number: