Durable Medical Equipment Authorization Request Form
Fax: 313-745-0399
Medical Management Phone: 877-501-0958
Date of Request:
_____________
Member’s Name: ________________________________________________
DOB: ________________
DMC Care ID#: ______________________________
Other Insurance: _____________________________________
Member’s Diagnosis: _____________________________________ ICD-10 Codes: ____________________________
Provider’s Name: _____________________________________________________________________________________
Provider’s Address: _____________________________________________________________________________________
Contact Person: _______________________________
Phone#: _________________ Fax#: ___________________
NPI #: ___________________________
Provider Tax ID #: ______________________________
Ordering Physician: ____________________________________ Specialty: ___________________________________
Dates of Service: Start _________________ End ______________
*MUST SUBMIT CURRENT CLINICAL & COPY OF SCRIPT
ITEM(S) REQUESTED
HCPCS CODE
QUANTITY
PRICE
PURCHASE OR RENTAL
Purchase
Rental
Purchase
Rental
Purchase
Rental
Purchase
Rental
Purchase
Rental
Purchase
Rental
Purchase
Rental
Purchase
Rental
MEDICAL MANAGEMENT USE ONLY:
Denied
Approved
Authorization#: ___________________
No Authorization Required
Staff Initials: _____________________
Date: ________________
PROVIDER MUST NOTIFY MEMBER: CO- PAYS, COINSURANCE & DEDUCTIBLES WILL APPLY FOR THIS SERVICE
A
D
NOT G
P
. P
D
E
D
S
UTHORIZATION
OES
UARANTEE
AYMENT
AYMENT
EPENDENT ON
LIGIBILITY ON
ATE OF
ERVICE
CONFIDENTIALITY NOTICE: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and/or privileged
information. If you are not the intended recipient(s), you are hereby notified that any dissemination, unauthorized review, use, disclosure or distribution of this
communication and any materials contained in any attachments is prohibited. If you receive this message in error, or are not the intended recipient(s), please immediately
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DMC Care 2016
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