BlueCross BlueShield of Tennessee Health Insurance
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: Rental:
Quantity Quantity
1. 4.
2. 5.
3. 6.
Clinical Information: (Attach records if needed)
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via the U.S. Postal Service. Thank you.
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