289 LaClair Street 2025

1. Click ‘Get Form’ to open the Durable Medical Equipment Prescription in the editor.
2. Begin by filling in the patient's NAME, DOB, and MEMBER # in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Next, provide the ADDRESS and PHONE number of the member. This helps in maintaining clear communication regarding their DME items.
4. Enter the ICD-10 Code, which is required for insurance purposes. Make sure to double-check this code for correctness.
5. Indicate whether items were dispensed by selecting YES or NO. This will guide further processing of the prescription.
6. Specify the LENGTH OF NEED in months, ensuring it aligns with the member's requirements.
7. Fill out details for specific DME items needed, including quantities per month for each item listed under diabetic supplies and other categories.
8. Complete the prescribing physician's information and ensure their signature is included before submitting.
9. Finally, fax your completed prescription to Advanced Health at 541-269-7147 directly from our platform for efficient processing.

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