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*note homefill code needed K0738

PECOS SEARCH

MEDICARE PROVIDERS ARE REQUIRED TO HAVE REGISTERED AS PECOS PROVIDERS.

BEFORE GETTING FINAL ORDER PECOS CERTIFICATION  MUST BE VERIFIED

check pecos here

check pecos here

PECOS SEARCH
WOPD CHECK
CHECK WOPD GUIDELINES:ONLY
*Submit for Manager Review AS NEEDED
Patients NAME, PRODUCTS ORDERED and DATE OF ORDER
PECOS PRACTITIONERS NAME, DATE SIGNED, AND NPI?
Is this item going to require ongoing supplies?
Are all items to be dispensed listed and DOSE/ROUTE of Administration (if appropriate)
Do we have quanitity, refills, & frequency of use?
Are all questions answered YES (IF YES, IT CAN BE SET UP PER WOPD) SUBMIT IF you still need manager review for approval of set up? Will send email to Angela Green

SUBMIT and follow up with patient name/ID # in secure email to manager: do not include patient identifying info on this form

© 2019. AGreen for Medi-Rents & Sales

Tel: 1.800.540.7252

Fax: 1.844.825.3613

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