Title xix 2014 form-2025

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 the 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, QRP name, taxonomy, benefit code, QRP TPI, and QRP NPI.
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. Ensure all necessary checkboxes are marked.
5. Complete Section B by entering diagnoses corresponding to each item from Section A. Justify medical necessity for each item and include any relevant details like height/weight or wound stage.
6. Finally, ensure that both the prescribing physician's signature and date are included at the end of the form. Remember that signature stamps are not acceptable.

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