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The document is a physician order form for Home Health Services (Title XIX) related to Durable Medical Equipment (DME) and medical supplies. It outlines the process for completing the order, including necessary information about the client, supplier, and physician. The form requires details on requested items, medical necessity justification, and must be submitted within 90 days of the physician's signature. It emphasizes the importance of certification regarding the appropriateness and safety of prescribed items for home use.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (47 Votes)
2012	4.8 Satisfied (33 Votes)
2011	4 Satisfied (54 Votes)
2006	4 Satisfied (31 Votes)

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