|
Section A:
|
|
|
Requested Durable Medical Equipment and Supplies
|
|
|
This section was completed by
|
|
|
Supplier Name
|
Supplier Address
|
|
Supplier Telephone
|
Supplier Fax
|
|
Supplier TPI
|
Supplier NPI
|
|
Supplier Taxonomy
|
Supplier Benefit Code
|
|
Physician Telephone
|
Physician Fax
|
|
I certify that the services being supplied...
|
|
|
1. HCPCS Code
|
Description of DME/medical supplies
|
|
Quantity
|
Price
|
|
Prior authorization required?
|
Beyond quantity time?
|
|
Custom Item?
|
|
|
2. HCPCS Code
|
Description of DME/medical supplies
|
|
Quantity
|
Price
|
|
Prior authorization required?
|
Beyond quantity time?
|
|
Custom Item?
|
|
|
3. HCPCS Code
|
Description of DME/medical supplies
|
|
Quantity
|
Price
|
|
Prior authorization required?
|
Beyond quantity time?
|
|
Custom Item?
|
|
|
4. HCPCS Code
|
Description of DME/medical supplies
|
|
Quantity
|
Price
|
|
Prior authorization required?
|
Beyond quantity time?
|
|
Custom Item?
|
|
|
5. HCPCS Code
|
Description of DME/medical supplies
|
|
Quantity
|
Price
|
|
Prior authorization required?
|
Beyond quantity time?
|
|
Custom Item?
|
|
