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MTC Durable Medical Equipment (DME) Request Form Required for: Managed Long Term CARFAX: (716) 8038727Email: mltcauthreq fideliscare.questions: (888) 3433547Member Information Fidel is Care Member
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01
Begin by downloading the 2019-fidelis-care-mltc-durable-medical-equipment-request-form-english from the official Fidelis Care website.
02
Ensure you have all the necessary information and documents required to fill out the form. This may include your personal information, medical history, and prescription details.
03
Carefully read through the instructions and sections of the form to familiarize yourself with the requirements.
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Fill out the form accurately and provide all the requested information. Make sure to double-check your entries for any errors or omissions.
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If there are any specific sections or questions that you are unsure about, consult the accompanying instructions or contact Fidelis Care for clarification.
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Once you have completed the form, review it again to ensure all the information is correct.
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Sign and date the form as required.
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Make a copy of the filled-out form for your records.
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Submit the completed form to Fidelis Care through the designated channels. This may include mailing the form or submitting it online, depending on the instructions provided.

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The 2019-fidelis-care-mltc-durable-medical-equipment-request-form-english is typically needed by individuals who are enrolled in Fidelis Care's MLTC (Managed Long-Term Care) program and require durable medical equipment.
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This form is specifically designed to request such equipment, such as wheelchairs, walkers, oxygen supplies, and other medically necessary devices or aids.
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It may be required for individuals with chronic illnesses, disabilities, or health conditions that necessitate the use of durable medical equipment in the long-term care setting.
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If you are unsure whether you need to fill out this form, it is recommended to consult with your healthcare provider or contact Fidelis Care directly for assistance.
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The fidelis-care-mltc-durable-medical-equipment-request-form-english is a form used to request durable medical equipment under Fidelis Care MLTC.
Members of Fidelis Care MLTC who need durable medical equipment are required to file this form.
The form must be completed with accurate information about the member, the requested equipment, and the healthcare provider's recommendation.
The form is used to request approval for durable medical equipment needed by members of Fidelis Care MLTC for their healthcare needs.
The form requires information about the member's medical condition, the prescribed equipment, and the healthcare provider's recommendation.
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