Fillable Printable DME Requests Fax Cover Sheet
Fillable Printable DME Requests Fax Cover Sheet
DME Requests Fax Cover Sheet
Date: DATE
To: Group Health-Pre-Service DME
1-888-282-2685
From: NAME
Phone: NUMBER
Fax: FAX NUMBER
Pages: # OF PAGES
Durable Medical Equipment (DME) authorization required information, please fill in the
sections below:
Vendor name (restrictions may apply, please see MyGroupHealth for Providers
website):
Vendor location (if applicable):
Ordering physician first and last name:
Diagnosis with ICD-9 code(s) (2 maximum):
HCPC code(s):
HCPC description or additional 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(s) 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):
Confidentiality Statement
The documents accompanying this facsimile transmission may contain confidential information belonging to the
sender that is protected by Washington state and/or federal law. This information is solely for the use of the
addressee named above. You may be exposed to legal liability if you disclose this information to another person. You
are obligated to maintain this information in a safe and secure manner.
If you are NOT the intended recipient, you are hereby notified that any disclosure, copying, distribution, or other use
of the contents of this faxed information is strictly prohibited. Please notify the sender immediately by telephone or
call the Group Health Privacy Office at 206-448-2422 to arrange for return of the documents to us.
