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Durable Medical Equipment Authorization Request Form Complete this form and fax to your choice of one of the authorized vendors Vendor Select One Date: Time: Contact Name: Contact Phone: Member Name:
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What is durable medical equipment?
Durable medical equipment is equipment that provides therapeutic benefits to a patient with certain medical conditions or illnesses.
Who is required to file durable medical equipment?
Healthcare providers or suppliers who provide durable medical equipment to patients are required to file.
How to fill out durable medical equipment?
To fill out durable medical equipment, providers must document the equipment provided, the medical necessity, and submit the required paperwork to insurance companies or government agencies.
What is the purpose of durable medical equipment?
The purpose of durable medical equipment is to assist patients in their daily activities, improve their quality of life, and support their medical treatment.
What information must be reported on durable medical equipment?
Information such as the type of equipment provided, the patient's medical condition, the prescribing physician, and the date of service must be reported on durable medical equipment.
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