Instructions: Complete all applicable fields on the form. Print or type all sections.
Item 1 Member’s Name Enter the member’s name as it appears on the MassHealth card.
Item 2 Member’s MassHealth
ID no.
Enter the member’s MassHealth identification number, which appears beside the member’s name on the
MassHealth card.
Item 3 Member’s DOB Enter the member’s date of birth in month/day/year order.
Item 4 Member’s address Enter the member’s permanent legal address (street address, town, and zip code).
Item 5 Primary diagnosis Enter the primary diagnosis name and ICD code that correspond to the condition for which the support surface is
being requested.
Item 6 Secondary diagnosis Enter the secondary diagnosis names and ICD codes (up to 3 codes) that correspond to other medical conditions
associated with the need for the requested support surface. Enter “N/A” if not applicable.
Item 7 Wound type(s) Place a checkmark beside all wound types that apply. If checking “Other,” specify the type not listed (for example,
non-healing wound) in the space provided. Use attachments as needed.
Item 8 Wound photo(s) Place a checkmark beside all types of documentation provided. If checking “Other,” specify the type of
documentation in the space provided. Attach the applicable documentation for each item checked.
Item 9 Wound description For each wound, enter in the spaces provided, the wound stage, location, size (length, width, depth), color, drainage,
tunneling, and undermining. Use attachments as needed.
Item 10 Functional status Place a checkmark beside all statuses that apply. If checking “Other,” specify the status not listed in the space
provided. Attach clinical information about all items checked.
Item 11 Mental status Place a checkmark beside all statuses that apply. If checking “Other,” specify the condition not listed in the space
provided. Attach clinical information as needed.
Item 12 Comorbid condition(s) Place a checkmark beside all conditions that apply. When indicated, specify the conditions in the space provided.
Attach clinical information about all items checked.
Item 13 Nutritional status Enter member’s height in inches, weight in pounds, ideal body weight (IBW) in pounds, and type of enteral and
parenteral supplements used. Attach clinical information as needed.
Item 14 Incontinence status Place a checkmark beside all that apply. If checking “Other,” specify the status not listed in the space provided.
Item 15 Drugs aecting
wound healing
Place a checkmark beside all that apply. Describe the types of oral or topical medications aecting wound healing in
the space provided.
Item 16 Wound care
plan includes
Place a checkmark beside all that apply. If checking “Wound treatments,” describe the treatments used (for
example, calcium alginates or hydrogel). If checking “Other,” describe the treatments not listed.
Item 17 Outcome of
treatment plan
Place a checkmark beside the appropriate response for each question asked.
Item 18 Location where member
will use item(s)
Place a checkmark beside all locations that apply to use of the product requested. If checking “Other,” specify the
location (for example, skilled nursing facility, end stage renal disease facility) in the space provided.
Item 19 Duration of need
(number of days)
Enter total number of days that prescriber expects the member to require use of the items requested. If “other” is
checked fill in blank.
Item 20 Type of support surface Place a checkmark beside all requested items. If checking “Other,” specify the type of support surface not listed in
the space provided.
Item 21 Description of
equipment
Enter a description of the item(s) requested (for example, accessories, supplies, or options).
Item 22 DME provider Enter the company name and address of the provider who will supply the support surface(s) being requested. If
available, also provide the DME provider’s telephone number and MassHealth provider number.
Item 23 Prescriber Enter the physician’s/clinician’s name, address, and telephone number where he or she can be contacted if more
information is needed. Include the prescriber’s MassHealth provider number, or if the prescriber is not a MassHealth
provider, enter the prescriber’s unique physician identification number (UPIN).
Item 24 Person completing form
on behalf of prescriber
If a clinical professional other than the treating clinician (for example, home health nurse or wound-care specialist)
or a physician employee answers any of the items listed he or she must print his or her name, professional title, and
name of employer (organization) where indicated.
Item 25 Attestation The prescriber must attest that the clinical information provided on the form is accurate and complete to the best of
the prescriber’s knowledge by signing this field.
Note: Prior-authorization requests with incomplete medical necessity documentation may be returned for more information or denied. Please refer to the
MassHealth Guidelines for Medical Necessity Determination for Support Surfaces for further information about submitting required clinical documentation.
