HTML Preview Medical Equipment Order Form page number 1.
Durable Medical Equipment and Medical Supplies
General Prescription and Medical Necessity Review Form
Eective Date of Prescription
Sections 1-5 must be completed by the DME provider. Sections 4A, 4B, 5A, 6, and 7 must be completed by the member’s prescribing provider.
Section 1 — Member’s Information
Member’s name MassHealth ID no.
Address Tel. no.
Date of birth (dd/mm/yy) Gender Height Weight
ICD code(s
Diagnosis
) ___________/__________/__________/___________/__________/__________
Section 2 — Prescribing Provider’s Information
Prescribing provider’s name Tel. no.
Address NPI
Fax no.
Section 3 — DME Provider Information
DME provider name
Address
Tel. no.
NPI
Fax no.
Section 4 — For Durable Medical Equipment Only
Items Requested
1.
2.
3.
4.
5.
6.
HCPCS Code Modifiers
Section 4A (Must be completed by prescribing provider or
the prescribing provider’s employee.)
Length of Need
1.
2.
3.
4.
5.
(See page 2 Section 4B, for additional listings.)
Section 5 — For Medical Supplies Only
Items Requested
1.
2.
3.
4.
HCPCS Code Modifiers
Section 5A (Must be completed by prescribing provider or
the prescribing provider’s employee.)
Quantity Monthly
1.
2.
3.
4.
Number of Refills
Section 6
Medical justification for requested item(s) along with any settings, therapeutic outcomes, and previous treatment plans (if applicable). Please attach any
pertinent documentation (i.e., lab tests, etc.).
Section 7 — Prescribing Provider’s Attestation, Signature, and Date
I certify that I am the prescribing provider identified in Section 2 of this form. Any attached statement on my letterhead has been reviewed and signed by me. I
certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to the best of my knowledge. I understand
that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Prescribing provider’s signature (Signature and date stamps are not acceptable) Date
DME-2 (Rev. 05/14)
continued
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