Title 19 2025

1. Click ‘Get Form’ to open the Title 19 Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form in the editor.
2. In Section A, indicate who completed the form by checking either 'Requesting Physician' or 'Supplier'. Fill in the client’s name and date of birth, and specify if the client is under 21 years of age.
3. Complete the supplier information including name, address, telephone, fax, TPI, NPI, Taxonomy, and Benefit Code. Ensure all fields are filled accurately for processing.
4. List each requested DME/medical supply item in the provided table. Include HCPCS codes, descriptions, quantities, prices, and check if prior authorization is required or if items are custom.
5. In Section B, provide diagnosis information correlating with each item from Section A. Include ICD-9 codes and a brief justification for medical necessity.
6. Fill in additional details such as height/weight and functionality/mobility status. Complete the 'Date last seen' and 'Duration of need' fields before signing.

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