Transcription of 508C, Durable Medical Equipment Request Form
1 1 Cameron Hill Circle Chattanooga, TN 37402 BlueCareSM TennCareSelect CoverKids Durable Medical Equipment Request Form To Request services: BlueCare/TennCareSelect/CoverKids Fax Number: 1-800-292-5311 FUrgent FDate of Service Correction FNon-Urgent FPrevious Auth #: Member Information Member discharged from hospital facility? FYes FNo If yes, discharge date: Recent surgery related to this Request ? FYes FNo Member Name: _____ Member ID Number: _____ Member Address: _____ Member Phone Number: _____Date of Birth: _____ Primary Diagnosis for Requested Item (List ICD-10 Codes):_____ Ordering Physician Ordering Physician: _____ Provider Number: _____ Phone Number: _____Fax Number: _____ National Provider Identifier:_____Tennessee Medicaid Number: _____ Address: _____ DME Provider Treating/Rendering Provider: _____ Provider Number: _____ Address: _____ Contact Name: _____ Phone Number: _____ Ext.
2 : _____ Fax Number: _____ FPurchase FRental HCPCS Code Modifiers (if applicable) Code Description Units Requested Date of Service Requested Duration 1 2 3 4 5 HCPCS Code Modifiers (if applicable) Code Description Units Requested Date of Service Requested Duration 6 7 8 9 10 11 12 13 14 15 This form is to be used to Request all DME services, and is not to be used as an order. Please attach the specific order for the Request that includes the type of service, the amount of services requested, the frequency of services and the duration of the Request . The Request on the order must match the Request on this form. Clinical Information: (Attach Medical records appropriate for this Request , including, but not limited to: clinical notes, lab and/or imaging results. If photos are required per the BlueCare Tennessee Medical Policy for review, please mail to the address at the top of page 1.)
3 Member Name: _____Member ID Number: _____ BlueCare Tennessee is an Independent Licensee of the BlueCross BlueShield Association 19 PED538681 (2/20)
