LAC 40:I.4317
LAC 40:I.4317. Billing Instructions
Cite as La. Admin. Code tit. 40, pt. I, § 4317
A. In addition to the HCFA 1500 Form, the completed Medical Certification Form (LDOL-WC-3002) must be submitted for all initial claims either rental or purchase.
B. DME 3002 Form
durable medical equipment certification
this form must be completed by the physician prescribing the equipment and attached to the claim filed by the supplier
patient's name | age | contract no.
equipment prescribed | date prescribed
diagnosis
limitations (Check all conditions applicable)
Weakness of arm(s) Weakness of leg(s) Unable to ambulate | Confined to chair Confined to bed Confined to home | Other
how long will the patient need this equipment (be specific)
if the equipment is for oxygen supplies, please provide the following information.
frequency of use | medical need for the equipment | expecteed benefit of receiving the oxygen therapy
if the equipment is for home blood glucose monitoring system, please provide the following information.
is the patient taking insulin? yes no | if yes, frequency? | degree of diabetic control?
ketosis? yes no | insulin reactions yes no | is patient pregnant? yes no
are other diabetic complications present (be specific)
physician's name address city state zip
physician's phone no. | physician's signature X | date