THP%20Durable%20Medical%20Equipment%20Prior%20Authorization%20Form%202023.002%2012.2023

Sep 17, 2026

Durable medical equipment prior authorization form collecting member identity, contact details, demographics, inpatient discharge status, and prescribing physician information including NPI and phone/fax. Includes DME provider details and a request section capturing request date, expected delivery date, item descriptions using HCPCS codes with units, rental or purchase type, and ICD-10 coding. Adds continuity of care dates for authorization periods, insurance effective dates, rental period start/end, and retroactive request indicators, plus submission instructions and confidentiality and HIPAA-related disclaimers.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Member Information

Ordering Physician Information

DME Provider Information

Request for Services

Description of DME Items Needed

Continuity of Care Information

Retroactive Request Information

Submission Instructions

| | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | Disclaimer Statements and Attestation
Prior Authorizations will be given for medically necessary services only: it is not a guarantee of payment. Payment is subject to verification of member eligibility and to the limitations and exclusions of the member’s contract. | | | | | | | | | | MEMBER INFORMATION | | | | | | | | | | Member ID\#: | | | | Last Name: | | | | First Name: | | Phone Number: | | | | Date of Birth: | | | | Gender: M F | | Street Address: | | | | | City, State, Zip: | | | | | Is Member Being Discharged From an Inpatient Facility? Yes No | | | | | | | | | | ORDERING PHYSICIAN INFORMATION | | | | | | | | | | Ordering Physician Name: | | | | | Ordering Physician NPI Number: | | | | | Ordering Physician Phone Number: | | | | | Ordering Physician Fax Number: | | | | | DME PROVIDER INFORMATION | | | | | | | | | | DME Provider Name: | | | | | NPI Number: | | | | | Street Address: | | | | | City, State, Zip: | | | | | Phone Number: | | | | | Fax Number: | | | | | REQUEST FOR SERVICES | | | | | | | | | | Request Date: | | | | | Expected Delivery Date of DME: | | | | | DESCRIPTION OF DME ITEMS NEEDED | | | | | | | | | | HCPCS Code: | | Number of Units: | | Description: | | | | | | HCPCS Code: | | Number of Units: | | Description: | | | | | | HCPCS Code: | | Number of Units: | | Description: | | | | | | Additional Codes: | | | | | | | | | | Type of request: Initial Device rental Continued Rental Replacement Purchase | | | | | | | | | | If Continued Rental, Date DME Delivered: If Continued Rental, Date of Service: | | | | | | | | | | Primary ICD10 Code(s): | | | | | | | | | | CONTINUITY OF CARE INFORMATION | | | | | | | | | | Effective Date of Insurance: | | | | | Initial Start Date of Rental Period: | | | | | Start Date of Current Authorization: | | | | | End Date of Current Authorization: | | | | | Months Left on Capped Rental: | | | | | | | | | | RETROACTIVE REQUEST INFORMATION | | | | | | | | | | Is this a Retroactive Request? Yes No Delivery Date: | | | | | | | | | |
To request Prior Authorizations for DME, log onto www.evicore.com for online submissions, or fax all of the following
documents to 866-663-7740 | | | | | | | | | | 1. This completed form
2. Current physician’s order/script
3. Current detailed invoice listing all requested equipment (if required)
4. Current clinical related to request (i.e. , patient history, progress notes and physical exams) | | | | | |
Call 877-791-4104 to speak with an eviCore healthcare representative | | | | | | | | | | | | | CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) . This information is intended only for the use of the recipient(s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify me and destroy the original transmission and its attachments without saving them in any manner. Page 1 of 1 The Health Plan 2023.002 12.2023

FAQs

What information does the form collect about the member?

It collects member ID, name, phone number, date of birth, gender, street address, and inpatient discharge status.

What details are required for ordering physician and DME provider?

The form requires ordering physician name, NPI, phone and fax, and DME provider name, NPI, address, phone, and fax.

How does the form request retroactive prior authorization?

It includes a retroactive request section asking whether the request is retroactive and the delivery date, along with continuity of care authorization dates.

Sep 17, 2026

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