ࡱ> %` !bjbj"x"x :&@@n\\\\ 8$ h#44444lll"""""""$Z$h&"9hh"\\444"#^\4\l4""!\,"4( pc@E@^!o"T8#0h#!,''"'"hl>,$lll""2^lllh#   d lD   l   \\\\\\ Durable Medical Equipment Request Form Commercial Phone Number: 1-800-924-7141 Fax Number: 1-866-558-0789 Member Information Member Name: ______________________________ Member ID Number: _________________________ Address: _________________________________________________________________________________ Date of Birth: ________________________ Member Phone Number: _____________________________ Diagnosis: (List all) ________________________________________________________________________ Physician and Supplier Information Ordering Physician: _________________________________________Provider Number: ______________ National Provider Identifier: _________________ Phone Number: _____________________________ Fax Number: _________________________________ Date of Order or Certificate of Medical Necessity: ______________________________________________ Supplier: ____________________ Address: _____________________ Provider Number: ______________ National Provider identifier: __________________ Tennessee Medicaid Number: ____________________ Phone Number: _____________________________ Fax Number: __________________________________ Contact: __________________________ Start Date: _________________ Duration: __________________ Equipment Codes Requested: Purchase: m Rental: m Quantity Quantity 1. 4. 2. 5. 3. 6. 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