Dme Certification And Receipt Form Page 4
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4DME Certification and Receipt Form
Certificación y Recibo de Equipo Medico Duradero (DME)
(Page 4 of 4—Not for submission to TMHP)
High Cost DME Call Verification
Your provider has sent you some medical equipment. We want to make sure that you got what you wanted and that it
works well. We need to talk to you about the equipment before we can pay for it.
Call TMHP at 1-888-276-0702.
Please call us toll-free at 1-888-276-0702 as soon as you can. We are open Monday through Friday from 7 a.m. to 7 p.m., Central
Time. If you call us after hours, you can leave a message. Tell us your name, phone number, and the best time to call you back.
Required Information
Please have this information with you when you call:
•
Name
•
Medicaid Number
•
Birth date
•
Address (street, city, state, ZIP)
•
Provider’s name
•
Date you got the equipment
•
Details about the equipment
F00018
Effective Date_07/01/2011/Revised Date_10/06/2011
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