DME Fax Information
To: HPP DME Medicaid Fax # (215) 849 – 4749 Medicare Fax # (267) 515 – 6636	DME Provider Name: Click or tap here to enter text.
NPI #: Click or tap here to enter text.
DME Contact: Click or tap here to enter text.	DME Phone #: Click or tap here to enter text.
Date: Click or tap to enter a date.	DME Fax #: Click or tap here to enter text.

Provider – Please Complete Area Below
Member Name: Click or tap here to enter text.	Member ID #: Click or tap here to enter text.	Member’s DOB: Click or tap to enter a date.
Dates of Service Requested: Click or tap to enter a date.	Duration of Service: Click or tap here to enter text.
ICD 10/Diagnosis: Click or tap here to enter text.	Description: (Description of medical condition/diagnosis) Click or tap here to enter text.
Ordering Physician Name: Click or tap here to enter text.	Phone # Click or tap here to enter text.
NPI #: Click or tap here to enter text.	Fax # Click or tap here to enter text.
Attachments (Supporting the Requested Clinical Service) ☐Physician signed Prescription ☐Letter of Medical Necessity (LMN) ☐DME Manufacturer’s Invoice (If applicable)	Authorization will be denied without documentation of Medical Necessity and PromiseID#.
Specifics of Request: e.g., volume, frequency, total number units. Note: Use NU or RR modifier as required. Click or tap here to enter text.

Please complete the HCPCS Codes section on page 2 of this form.

Use applicable HCPCS codes: Not otherwise classified codes will only be authorized in very specific circumstances.

Procedure HCPCS Code(S)	Description, Units & Price(S)
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