Title XIX Home Health Durable Medical Equipment ... - TMHP.com 2026

1. Click ‘Get Form’ to open it 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, Medicaid number, and date of birth. Confirm if the client is under 21 years of age.
3. Provide supplier details including name, Medicaid TPI number, address, and contact information. Ensure that the prescribing physician's information is also filled out accurately.
4. List the requested Durable Medical Equipment (DME) items in the table provided. Include item numbers, HCPCS codes, descriptions, quantities, prices, and check if prior authorization is required.
5. In Section B, enter diagnosis codes and provide justification for medical necessity for each item listed in Section A. Include any relevant patient details such as height and weight.
6. Ensure all signatures are completed where required. The prescribing physician must sign and date the form to validate it.

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