Title xix form 2013-2025

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492 votes

The document is a Title XIX Home Health Services Durable Medical Equipment (DME) and Medical Supplies Physician Order Form, which outlines the process for requesting DME and medical supplies. It includes sections for client and supplier information, details on requested items, diagnosis justification, and physician certification of medical necessity. The form must be completed by the prescribing physician and cannot be accepted beyond 90 days from the date of signature.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (201 Votes)
2014	4.4 Satisfied (565 Votes)
2013	4.4 Satisfied (492 Votes)

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