Prior Authorization / Durable Medical Equipment Attachment Page 2

Download a blank fillable Prior Authorization / Durable Medical Equipment Attachment in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Prior Authorization / Durable Medical Equipment Attachment with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

PRIOR AUTHORIZATION / DURABLE MEDICAL EQUIPMENT ATTACHMENT (PA/DMEA)
Page 2 of 2
F-11030 (07/12)
SECTION III — SERVICE INFORMATION (continued)
10. Is the member able to operate the equipment / item requested?

Yes
No — If not, who will do this?
11. Is training provided or required?
 
—
Yes
No
If not, who will do this?
Explain.
12. State where equipment / item will be used.
 
Home
Office
 
Nursing Home
Job
 
School
Describe type of dwelling and accessibility.
13. State estimated duration of need.
14. If renewal or continuation of DME authorization is requested, describe the following about the member, including current clinical
condition, progress (improvement, no change, etc.), results, and the member’s use of equipment / item prescribed.
15. Indicate amount of oxygen to be administered.
____ Liters per minute
Continuous
____ Hours per day
PRN
____ Days per week
PaO
2
Attach a photocopy of the physician’s prescription to this attachment. The prescription must be signed and dated within six months of
receipt by ForwardHealth.
16. SIGNATURE — Requesting Provider
17. Date Signed
Reset Form

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Prior Authorization / Brand Medically Necessary Attachment Prior Authorization / Brand Medically Necessary Attachment Medical
Prior Authorization Spell Of Illness Attachment Prior Authorization Spell Of Illness Attachment Legal
Durable Medical Equipment And Respiratory Medical Gas, Equipment And Supplies Face-to-face Encounter Durable Medical Equipment And Respiratory Medical Gas, Equipment And Supplies Face-to-face Encounter Medical
Durable Medical Equipment Authorization Request Form Durable Medical Equipment Authorization Request Form Medical
Durable Medical Equipment (dme) Supplier License Application Instructions Durable Medical Equipment (dme) Supplier License Application Instructions Legal
Prior Authorization / Home Health Therapy Attachment (pa/hhta) Prior Authorization / Home Health Therapy Attachment (pa/hhta) Business
Certificate Of Medical Necessity Durable Medical Equipment And Supplies Template Certificate Of Medical Necessity Durable Medical Equipment And Supplies Template Medical
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Prior Authorization/health And Behavior Intervention Attachment Form Prior Authorization/health And Behavior Intervention Attachment Form Medical
Prior Authorization / Adult Mental Health Day Treatment Attachment (pa/amhdta) Prior Authorization / Adult Mental Health Day Treatment Attachment (pa/amhdta) Business

Related Categories

Parent category: Medical
Download
Go
Page of 2