DME Authorization Request Form

Date of Request:

Requirements: Clinical information and supportive documentation should consist of current physician order,

notes and recent diagnostics. Test results must be submitted to support request for approval. Notification

required for any date of service change.

Fax completed form to: Horizon NJ Health 1-609-583-3023

General Information

Member Name: Member ID #: DOB:

Member Address: Member Phone #:

DME Provider Name: Provider Contact Name:

DME Provider Contact Phone #: DME Contact Fax #:

Medical Information Needed

Date/Date Range of Service:

Primary Diagnosis: Other Chronic Diagnosis:

ICD-10 Codes:

Required Information

DME:

HCPC:

Qty:

Ordering Physician Name: Provider ID #: & NPI #:

DME Servicing Provider: Provider ID #:

Authorization Information

□

Initial Auth Request

⁭ Auth Extension Request ⁭ Previous Auth

Comments:

Revised Date 4/2018 DME Authorization Form

In place of this form, you can submit Authorization Requests online securely via NaviNet. If you are not registered,

please visit NaviNet.net and click Sign Up or call NaviNet Customer Care at 1-888-482-8057.