Authorization For Durable Medical Equipment And Or Medical Supplies {MA 312} | Pdf Fpdf Docx | Pennsylvania

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Authorization For Durable Medical Equipment And Or Medical Supplies {MA 312} | Pdf Fpdf Docx | Pennsylvania

Last updated: 4/23/2019

Authorization For Durable Medical Equipment And Or Medical Supplies {MA 312}

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Description

OFFICE OF MEDICAL ASSISTANCE PROGRAMS HOME HEALTH SERVICESAUTHORIZATION FOR MEDICALLY NEEDY RECIPIENTS TO RECEIVEDURABLE MEDICAL EQUIPMENT AND/OR MEDICAL SUPPLIES PATIENT222S RECIPIENT NUMBERPATIENT222S NAME - Last Name - First - Middle Initial DURABLE MEDICAL EQUIPMENT NAME OF ITEM(S) MEDICAL SUPPLIESNAME OF ITEM(S)Commonwealth of Pennsylvania þ Department of Human Services þ MA 312 3/19DHS COPY / FILE COPY I understand that my signature certifies that the need for the item(s) is necessary as part of the patient222s plan of care.PRESCRIBING PHYSICIAN222S NAMEDATESIGNATURE HHA REPRESENTATIVEDATE American LegalNet, Inc. www.FormsWorkFlow.com

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