To: / Group Health-Review Service DME
1-877-290-4632
From: / NAME
Phone: / NUMBER
Fax: / FAX NUMBER
Pages: / # OF PAGES
Necessary information for an authorization, all applicable sections below are required:
· Vendor name:
· Vendor location (if applicable):
· Ordering physician tax identification number:
· Ordering physician first and last name:
· Diagnosis with ICD-10 code(s) (2 maximum):
· HCPC Code(s):
· HCPC description or additional equipment information:
· Length of need:
· Start date of authorization:
· Patient ID number:
· Patient first and last name:
· Patient DOB:
· Patient height and weight:
· Delivery address for equipment:
· Phone number to reach patient for delivery:
· Durable Power of Attorney/Patient advocate contact name and phone number (if applicable):
· Saturation and liter flow (for oxygen only):
· Settings for equipment (for CPAP/BIPAP only):
Submitter contact phone number:
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