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Durable Medical Equipment DME Request Form Must Be Filled Out Completely and Legibly Submission of request form required for Fully Integrated Duals Advantage Plan FIDA Fax 1. 212. 908. 4401 MetroPlus Member Name Last First M. I. Questions 1. 844. 288. 3432 Patient / Member Information Date of Birth mm/dd/yyyy Name/Title Provider Address City State Zip Phone include area code Provider Tax ID Fax include area code Ordering Doctor Name DME Services ICD 10 Code s and descriptions CPT/HCPCS Code s...

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