Title xix form 2013-2026

1. Click ‘Get Form’ to open the Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form in the editor.
2. In Section A, indicate who completed this section by checking either 'Requesting Physician' or 'Supplier'. Fill in the client information including date of birth, Medicaid number, and client name.
3. Provide supplier information such as name, telephone, fax number, address, TPI, NPI, taxonomy, QRP TPI, QRP name, and benefit code. Ensure all fields are accurately filled out.
4. In the DME/medical supplies table, list each item requested along with its HCPCS code, description, quantity, price, and whether prior authorization is required. Check the appropriate boxes for custom items or quantity limits.
5. Move to Section B where the prescribing physician must enter diagnosis details corresponding to each item from Section A. Include justifications for medical necessity and any additional relevant information.
6. Finally, ensure that both the prescribing physician's signature and attestation are completed along with their license number and TPI. Remember that signature stamps are not acceptable.

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