Medical Equipment Order Form
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Provider of DME’s signature Printed legal name of provider Printed legal name of individual signing Date page 2 Instructions for Completing the Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form (Sections 1, 2, 3, 4, and 5 must be completed by DME provider.) Instructions for Use of this Form DME providers should use this form when obtaining a prescription and letter of medical necessity from the member’s prescribing provider for DME, and as an attachment to a prior authorization request...
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