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Elizabeth M. Whitehorn, Director

Provider Notice issued 11/22/13

New DME Forms for Standard Manual Wheelchairs; Enteral Nutrition; and Food Thickeners

To:​ Enrolled Durable Medical Equipment and Supplies (DME) Providers; Pharmacies; Long Term Care Facilities; and Supportive Living Facilities​
Date:​ ​November 22, 2013
Re:​ New DME Forms for Standard Manual Wheelchairs; Enteral Nutrition; and Food Thickeners​

The department has developed three new DME forms to better identify to providers the information required by the department for review of prior approval requests. Effective with the date of this notice, HFS will require that providers submit these forms in addition to the existing HFS 1409 Prior Approval Request (pdf) form for specified DME items.

All of the new forms referenced below are available in a PDF-fillable format on the department's Medical Programs Forms page.

  • HFS 3701L, Standard Manual Wheelchair Evaluation, is required for all requests for rental of any type of manual wheelchair.

  • HFS 3701M, Questionnaire for Food Thickeners, is required for all requests for food thickeners.

  • HFS 3701N, Questionnaire for Enteral Nutrition, is required for all requests for enteral nutrition.

Any questions regarding this notice may be directed to the DME Prior Approval unit in the Bureau of Comprehensive Health Services at 1-877-782-5565, option 5, option 1.

Theresa A. Eagleson, Administrator

Division of Medical Programs