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Hca 13 794 2026
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- Click ‘Get Form’ to open the hca 13 794 in the editor.
- Begin by filling out Section I with the patient's name, date of birth, diagnosis, and length of need. If applicable, indicate whether the rental is for less than or greater than six months.
- In Section II, specify the item required and the quantity. Additionally, detail the frequency of use for supplies.
- Proceed to Section III where you will enter the physician’s printed name, address, telephone number, fax number, city, state, zip code, and NPI number.
- Finally, ensure that the physician signs and dates the form in the designated area to certify accuracy and completeness.
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Related links
HCA 13-794 (04/24). Prescription form. (standard written order). This prescription is valid for one (1) year from the date signed. 1. General information.Read more
The date on this form (HCA 13-727) must not be dated prior to the date on the Prescription Form (HCA 13-794);. (d) The make, model, and serial number of theRead more