Texas Title XIX - Patient Initiated Request
Your patient who has a TX Medicaid plan recently ordered medical equipment from us. To fill that order, please fill out this electronic Texas Medicaid Title XIX form below. If you encounter any issues, please email us at breastpumps@acelleron.com or call us directly at 877-932-6327.
Client/Patient Information
Client/Patient First and Last Name
*
Client/Patient Medicaid Number
*
Client/Patient Date of Birth
*
/
Month
/
Day
Year
Date
Rendering Provider Information:
I certify that the services being supplied under this order are consistent with the physician or allowed practitioner’s determination of medical necessity and prescription. The prescribed items are appropriate and can safely be used in the client’s home when used as prescribed. Rendering Provider’s Signature:
Date
/
Month
/
Day
Year
Date
Rendering Provider First and Last Name
Requesting Physician or Allowed Practitioner Information
First and Last Name
*
Telephone
*
Format: (000) 000-0000.
Fax
*
Format: (000) 000-0000.
Email (if you want to receive Title XIX for your records)
Optional field
Medical equipment/supplies needed
Select the items you would like to prescribe.
Item #1
*
Please Select
E0603
A6530
A4670
E0603 = Breast Pump | A6530 = Compression | A4670 = Automatic Blood Pressure Monitor
Description of DME
*
Quantity
Please Select
1
Socks Quantity
Please Select
2
4
6
8
Item #1 Diagnosis Code
Please Select
Z39.1
O92.70
O92.50
O92.03
Z39.1 = Breastfeeding Mother | O92.70 = Unspecified disorders of lactation | O92.50 = Suppressed Lactation | O92.03 = Retracted nipple associated with lactation
Item #1 Diagnosis Code
Please Select
R60.9
O12.00
O12.04
O12.05
R60.9 = Edema | O12.00 = Gestational edema, unspecified trimester | O12.04 = Gestational edema, complicating childbirth | O12.05 = Gestational edema, complicating the puerperium
Item #1 Diagnosis Code
Please Select
O13.9
I10
O16.9
O11.5
O16.5
O13.9 = Gestational hypertension | I10 = Primary hypertension | O16.9 = Unspecified maternal hypertension | O11.5 = Pre-existing hypertension with pre-eclampsia complicating the puerperium. | O16.5 = Unspecified maternal hypertension, complicating the puerperium.
Brief Diagnosis Description
*
Item Number
Item #2 (if needed)
Item #2
Please Select
A4670
A6530
E0603
E0603 = Breast Pump | A6530 = Compression | A4670 = Automatic Blood Pressure Monitor
Description of DME
Quantity
Please Select
1
2
4
6
8
Socks Quantity
Please Select
2
4
6
8
Item #2 Diagnosis Code
Please Select
Z39.1
O92.70
O92.50
O92.03
Z39.1 = Breastfeeding Mother | O92.70 = Unspecified disorders of lactation | O92.50 = Suppressed Lactation | O92.03 = Retracted nipple associated with lactation
Item #2 Diagnosis Code
Please Select
R60.9
O12.00
O12.04
O12.05
R60.9 = Edema | O12.00 = Gestational edema, unspecified trimester | O12.04 = Gestational edema, complicating childbirth | O12.05 = Gestational edema, complicating the puerperium
Item #2 Diagnosis Code
Please Select
O13.9
I10
O16.9
O11.5
O16.5
O13.9 = Gestational hypertension | I10 = Primary hypertension | O16.9 = Unspecified maternal hypertension | O11.5 = Pre-existing hypertension with pre-eclampsia complicating the puerperium. | O16.5 = Unspecified maternal hypertension, complicating the puerperium.
Diagnosis Description
Item #2
End
Item #3 (if needed)
Item #3
Please Select
A4670
A6530
E0603
E0603 = Breast Pump | A6530 = Compression | A4670 = Automatic Blood Pressure Monitor
Description of DME
Quantity
Please Select
1
Socks Quantity
Please Select
2
4
6
8
Item #3 Diagnosis Code
Please Select
Z39.1
O92.70
O92.50
O92.03
Z39.1 = Breastfeeding Mother | O92.70 = Unspecified disorders of lactation | O92.50 = Suppressed Lactation | O92.03 = Retracted nipple associated with lactation
Item #3 Diagnosis Code
Please Select
R60.9
O12.00
O12.04
O12.05
R60.9 = Edema | O12.00 = Gestational edema, unspecified trimester | O12.04 = Gestational edema, complicating childbirth | O12.05 = Gestational edema, complicating the puerperium
Item #3 Diagnosis Code
Please Select
O13.9
I10
O16.9
O11.5
O16.5
O13.9 = Gestational hypertension | I10 = Primary hypertension | O16.9 = Unspecified maternal hypertension | O11.5 = Pre-existing hypertension with pre-eclampsia complicating the puerperium. | O16.5 = Unspecified maternal hypertension, complicating the puerperium.
Diagnosis Description
Item #3
End
Date last seen by physician or allowed practitioner:
*
-
Month
-
Day
Year
Date
Duration of need for DME (months):
*
Please Select
99
1
2
3
4
5
6
7
8
9
10
11
Select 99 for lifetime as these are all purchase items.
By signing this form, I hereby attest that the information in Section “A”, with the exception of the rendering provider’s signature, was complete at the time of my signature and is consistent with the determination of the client’s current medical necessity and prescription. By prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate and can safely be used in the client’s home when used as prescribed. -------------------------------------------------------------------------------------Signature and Attestation of Requesting Physician or Allowed Practitioner:
*
Date
*
/
Month
/
Day
Year
Date
NPI
*
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