Title XIX - Facility Initiated Request
Use this form to electronically prescribe a breast pump, compression socks, or blood pressure monitor for a patient that has either a commercial or Medicaid plan in Texas. If you encounter any issues, please email us at breastpumps@acelleron.com or call us directly at 877-932-6327.
Patient Information
Enter your patient's information below.
Patient First and Last Name
*
As listed on Insurance Card
Patient Preferred Language
*
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Email Address
example@example.com
Patient Mobile Phone
*
Please enter a valid phone number. Patient will receive a text to select their equipment/supplies.
Format: (000) 000-0000.
Patient Primary Insurance
Please Select
Aetna Better Health TX (Medicaid)
Aetna (Commercial)
Ambetter Health
Ascension SmartHealth
BCBS of TX (Commercial)
BCBS of TX Star Plan (Medicaid)
Community First (Medicaid)
Community Health Choice (Medicaid)
Cook Children's Health Plan (Medicaid)
Dell Children's Health Plans (Medicaid)
Driscoll Children's Health Plan (Medicaid)
Molina Healthcare of TX (Medicaid)
Scott&White RightCare (Medicaid)
Sendero Health Plans
Superior HealthPlan (Medicaid)
Texas Children's Health Plan (Medicaid)
United Community of TX (Medicaid)
United Healthcare (Commercial)
Wellpoint of TX (Medicaid)
Patient Insurance ID
*
Patient Secondary Insurance
Patient Secondary Insurance ID
Baby Due/Birth Date (if prescribing a breast pump)
-
Month
-
Day
Year
Not needed for compression socks or blood pressure monitor.
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
Facility/Practice Name
Enter the facility name that the Provider is prescribing from.
First and Last Name
*
Telephone
*
Format: (000) 000-0000.
Fax
*
Format: (000) 000-0000.
Enter email for copy of completed form
Optional
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 Information 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 information 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
*
Would you like a copy of the completed form emailed to you?
Yes
No
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