Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form ‘See instructions for completing Tie XD Home Heath Durable Medical Equipment (OME}/Medkcal Supplies Physician Order Frm. Thc order form cannot ‘be acepted beyond 90 days rom the dat ofthe physian'ssignatwe. Mie at knee | certify and affirm that | am either the Provider, or have been specifically authorized by the Provider (hereinafter “Prior Authorization Request Submitter’) to submit this prior authorization request. The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are personally acquainted with the information supplied on the prior authorization form and any attachments or accompanying information and that it constitutes true, correct, complete and accurate information; does not contain any misrepresentations; and does not fail to include any information that might be deemed relevant or pertinent to the decision on which a prior authorization for payment would be made. ‘The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the information supplied on the prior authorization form and any attachments or accompanying information was made by a person with knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the ordinary course of business of the Provider; is the original or an exact duplicate of the original; and is maintained in the individual patient's medical record in accordance with the Texas Medicaid Provider Procedures Manual (TMPPM). The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that prior authorization is a condition of reimbursement and is not a guarantee of payment. The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior ‘authorization willbe from Federal and State funds, and that any false claims, statements or documents, concealment of a material fact, or omitting relevant or pertinent information may constitute fraud and may be prosecuted under applicable federal and/or State laws. The Provider and Prior Authorization Request Submitter understand and agree that failure to provide true and accurate information, omit information, or provide notice of changes to the information previously provided may result in termination of the provider's Medical enrollment and/or personal exclusion from Texas Medicaid, The Provider and Prior Authorization Request Submitter certify affirm and agree that by checking "We Agree" that they have read and understand the Prior Authorization Agreement requirements as stated in the relevant. Texas Medicaid Provider Procedures Manual and they agree and consent to the Certification above and to the Texas Medicaid & Healthcare Partnership (TMHP) Terms and Conditions. 00030 Page 1 of 2 Revised Date: 02/01/2016 | Effective DatHome Health Services (Title XIX) DME/Medical Supplies Physician Order Form See instructions for completing Title XD Home Heath Durable Medial Equipment (OMEY/Medlcal Supples Physician Order Form. This order form cannot be ‘accepted beyond 90 days fom the date ofthe physicians signature, [This section was completed by (check one}: Cl Requesting Physician 0) Supy [Medicaid number : [Date of ‘Supplier Information Telephone Faxnumber: Taxonomy: Benefit Code: (oR Ter: [ORF NPE certy thot the services being supplied under this order are consistent with the physiclon’s determination of medicalnecessityand prescription, The prescbed items are appropriate and can safely be used inthe client's home when weed as prescribed. Description of 7 Prior DMEmedcal supplies authorization required? oy on oy ON oy ON [ oy on medical necessity for requested items)" fer to Section A footnote 1) tbe fitedin. [Date ast seen phys [Duration need forme month) [Duration of need torsupples____ month signing tis form, hereby ales tht the informatonin Section “A, with the exception of the DME providers signature wos complete the ime of my signature and s consistent with the determination ofthe client's curent medical necessity and prescription. 8 [prescribing the identified DME and/or medical supplies, | certify the prescribed items are appropriate and can safely be used in the client’s| nome when used as prescribed. Signature and attestation of prescribing physician: Date: Signature stamps and date stamps arenot acceptable License number: 00030 Page 2of2 Revised Date: 02/01/2016 | Effective DatTexas Standard Prior Authorization Request Form for Health Care Services ‘Texas Department of Insurance call instructions. u Please send this request to the issuer from whom you are seeking authorization. Do nat send this form to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient's or subscriber's employer. Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standard Prior Authorization Request Form for Health Care Services if the plan requires prior authorization of a health care service. In addition to commercial issuers, the following public issuers must accept the form: Medicaid, the Medicaid managed care program, the Children’s Health insurance Program (CHIP), and plans covering employees of the state of Texas, most ‘School districts, and The University of Texas and Texas A&M Systems, Intended Use: When an issuer requires prior authorization of a health care service, use this form to request authorization by fax or mail. An issuer may also provide an electronic version of this form on its website that you can complete and submit electronically, via the issuer's portal, to request prior authorization of a health care service. Do not use this form to: 1) request an appeal; 2) confirm eligibility; 3) very coverage; 4) request a guarantee of payment; '5) ask whether a service requires prior authorization; 6) request prior authorization of a prescription drug; or 7) request a referral to an out of network physician, facility or other health care provider. itional informatic ictions: Section |. An issuer may have already entered this information on the copy of this form posted on its website, Section il. Urgent reviews: Request an urgent review for a patient with a life-threatening condition, or for a patient who is currently hospitalized, or to authorize treatment following stabilization of an emergency condition, You may also request an urgent review to authorize treatment of an acute injury or illness, ifthe provider determines that the condition is severe r painful enough to warrant an expedited or urgent review to prevent a serious deterioration of the patient’s condition or health, Section IV. © Ifthe Requesting Provider or Facility will also be the Service Provider or Facility, enter “Same.” ‘Ifthe requesting provider's signature is required, you may not use a signature stamp, ‘Ifthe issuer's plan requires the patient to have a primary care provider (PCP), enter the PCP’s name and phone ‘umber. If the requesting provider is the patient’s PCP, enter “Same.” Section Vi, * Givea brief narrative of medical necessity in this space, or in an attached statement. ‘© Attach supporting clinical documentation (medical records, progress notes, lab reports, etc.) if needed. ‘Note: Some issuers may require more information or additional forms to process your request. if you think an additional form may be needed, please check the issuer's website before faxing or malling your request. Jf the requesting provider wants to be called directly about missing information needed to process this request, you may include the provider's direct phone number in the space given at the bottom of the request form. Such o phone call cannot be considered a peer- tospeer discussion required by 28 TAC §19.1710. A peer-to-peer discussion must include, at a minimum, the clinical bass forthe URA's decision and a description of documentation or evidence, if any, that can be submitted by the provider of record that, on appeal, might lead to « different utilzation review decision. ‘Texas Department of Insurance | 338 Guadalupe | Austin, Texas 78701 | (800) 578-4677 | vaww.tditexas gov | @TexasTD!‘TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM FOR HEALTH CARE SERVICES SECTION I — SuBMissION =. ne (i Clinical Reason for Urgency: Review Type: [_]Non-Urgent —["] Urgent Request Type: [] initial Request [_] Extension/Renewal/Amendment Prev. Auth. Phone: oe: ‘sex L] Male [] Female (unknown Subsrber ane iar Wert Sree crop | Recuesting Provider or Facity Service Provider or Fecity ] ‘Name: Name: | ie Spedty ane ieee hone = mone S Contact Name: Phone: ew ee I iain roar Since ed ble SUSIE fae | SECTION V — SERVICES REQUESTED (wir CPT, CDT, oR HCP ‘SUPPORTING DIAGNOSES (WrrH ICD CDE) Ciinpatient EJoutoatont Crow Ci bay Surgery (J Other: Physica! therapy [Occupational Therapy [-] Speech Therapy [] Cardiac Rehab [] Mental Heafth/Substance Abuse Number of Sessions: Duration: Frequency: other: Come Health (MD signed Order attached? [¥es []No) (Nursing Assessment Attached? L-]Yes []No) | Number of Visits: Duration: Frequency: Other: | miccmeaet yo Ln) ona an TES Cro codes) uration: | SEGIONVI= Gunient Doconamon GeEINSteucrions Pact, SEcrION VD | HoeeS x 2 (we tor wrwonsnsSs — {An issuer needing more information may call the requesting provider directly at NoFRoo1 | 0115 Page 2 of 2TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM FOR HEALTH CARE SERVICES SeCTION I — SUBMISSION Fax Date [PRP cook Children's Health Pian!" 300-064-2247] | SECTION Il — GENERAL INFORMATION [clniat Reason for Urgency —— ae Cinontent Gloupatiene (pro ider Office LJ Observation L Coay surgery C] other CiPhysica' therapy Cloccupational Therapy L]speeeh Therapy [cardiac Rehob [-] Mental Heath/Substance Abuse umber of Sessions Duration: Frequency othe [iHome Heath (Mio signed Order tached? L]ves LJNa) (Nursing Assessment Attached? L]ves C]No) | Number of Visits: Duration: ftequency: other: Clome (m0 Siened order awached? L]ves L]no) (tMedicold only: Title 19 Certfeation Atached? fil] ves L] No} Euipmant/Supples clude any HCPCS codes) Duration | SEERON VI Cunstens DocumessrATION (SEEISTRUCTIONS PAGE SecrION VD E2103x1 faszaa6 UONIKS POL LeMonins Page 2of2 ‘Souret: Drag & Drop -chowtt (riginal document #6102258 received on 2/28/2023 12:27 PM ESTHome Health Services (Title XIX) DME/Medical Supplies Physician Order Form See ineruconfr competing Tile XkHore Heslh Durable Neda Equlpment(OMEYMedieal Sapp Physican Oder Ferm This rer fom cannot be copend beyond 9 dys hom he at the piping. [Section A: Requested Durable Medical Equipment and Supplies section was completed by check anal: 0 Requesting Physiclan i Supplier thony Rey Lopez 27576530, 712007 *REMIER KIDS CARE (@88) 692-0001 [Foxrumiber (866) 810-4027 '3148 PARK CENTER DRIVE, TYLER, TX 75707-6482 1072304 [wpe 1447321674 }2500000X Benefit Code: Frame: fore et aR? Ne: cert that he services being supplied under this dar ate consistent with he physicians determination of medleal necessity and prescription. The prescrived tems are appropriate and can safely be used nthe client's home wher used as presribed. Dae made supplies provider representative rare (Typed or Pi awrence Swanson (682) 885-7960 (682) 885-3943 Tree Berend] Caton ‘tn iar 1 |E2103. |DEXCOM RECEIVER G7_ 1 42Y ON [OY ON [OY On 2 |Aaza9 |CGM THERAPEUTIC SUPPLIES 8 @y ON [oY ON oY on 3 oy ON [oy ON|oy oN ~ oy on jovon|oy on Yo detonal dournetation mat be provided wo suppor determination of medal necessity Section 8: Diagnosis and Medical Need Information Co ref bagrors ORT Sagi jecnton or aetaatonaT umber ‘mecca ec forrquested emt) 2 [= {hatrto Scion A footote 7 ts = 2 ach te vequeste in Seton A musthave corelatng Gignosis and medical neces jusfcaion Ent al tem numbers rom the table Section ha eran to each agnosis. ange of tam numbers may be ented. Fapplieabeindude eighvweight, wound tageldimensons and funcionaimobity status Wote The "Date ast seen" and “Duration of need" items must befiledin. [Date ast seen byphrakan: E\~ 1&- Od OS i< [Duration ofneed for DMe:_Co__menth ) [Duration of need for supplies month (3) [oy stoning ths torn hereby attest that the Information i Section "A" with the exception of the DME provider's signature, was Complete atthe time of my signature ands consistent with the determination of the client's current medical necessity and prescription. BY prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate and can safely be usedin the lent’ ome when used as prescribed. signature and os > D8 2093) Sans amp die ome ees T rescrbing physi TP] DATS we [oH SS License rumber 23 Source: Diag & Drop -chewat ‘Odsal document #6102259 ceived on 2728/2023 1227 PM EST