Texas Medicaid home health DME and medical supply providers need this three-page order, completed and signed, before they request prior authorization from TMHP, and it serves as the prescription. The supplier or prescriber lists items by HCPCS code in Section A; the physician or allowed practitioner adds diagnoses, medical necessity, duration of need and the date last seen in Section B, then signs. The DME provider submits it to TMHP with the prior authorization request.
Section A can be completed by the rendering DME provider or by the requesting physician or allowed practitioner (a checkbox shows which), and the rendering provider signs its certification. Section B must be completed and signed by the requesting physician, nurse practitioner, clinical nurse specialist or physician assistant; chiropractor signatures are not accepted.
Page 1 holds the certification that the provider or its authorized submitter accepts by checking 'We Agree': the information is true and complete, is kept in the patient's record as the Texas Medicaid Provider Procedures Manual requires, and prior authorization is a condition of reimbursement, not a guarantee of payment. False statements may be prosecuted and can end Medicaid enrollment. The page also describes the two submission channels, PA on the Portal and fax.
Check whether the requesting physician or allowed practitioner or the rendering provider completed this section. Enter the client's name, Medicaid number and date of birth, then the rendering provider's name, address, Tax ID, NPI, taxonomy and benefit code, and the requesting prescriber's name. For each item give the HCPCS code, description and quantity, plus the MSRP only if the item needs manual pricing. Mark whether each item needs prior authorization, exceeds a quantity limit or is custom.
For wheeled mobility systems or major modifications to one, the supplier or Qualified Rehabilitation Professional must complete the QRP name, NPI, address, Tax ID, benefit code and taxonomy fields. The rendering provider then signs, dates and prints its name under the certification that the items match the prescriber's determination of medical necessity and can safely be used in the client's home.
This is the prescription and must be completed by the requesting physician or allowed practitioner. For each diagnosis, enter the Section A item numbers it supports (a range is fine), the diagnosis code, a brief description and a complete justification of medical necessity. You do not need to repeat the HCPCS code or item description. Every requested item must have a correlating diagnosis and justification.
Where applicable, add height and weight, wound stage and dimensions, and functional or mobility status. Enter the duration of need in months separately for DME and for supplies; the instructions give examples such as six weeks, three months or lifetime. Both duration of need and the date last seen must be completed, and the date last seen must be within 6 months of the start of services.
By signing, the prescriber attests that Section A, apart from the rendering provider's signature, was complete at the time of signing and matches the client's current medical necessity, and that the items are appropriate and safe for home use. Signature stamps and date stamps are not acceptable. Enter your NPI and license number. The form becomes a prescription at this point and cannot be altered afterward.
Download the current version from the source each time; forms change without notice.
Home Health Services (Title XIX) DME/Medical Supplies Prescribing Provider Order Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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TMHP cannot accept the form beyond 90 days from the date the prescribing physician or allowed practitioner signed it. Separately, the date the client was last seen by that prescriber must fall within 6 months of the start of services, so check both dates before the supplier submits the request.
The requesting physician or allowed practitioner (a nurse practitioner, clinical nurse specialist or physician assistant) completes and signs Section B and enters an NPI and license number. TMHP does not accept signatures from chiropractors, and signature stamps and date stamps are not acceptable. The rendering DME provider signs its own certification in Section A.
Fields marked with an asterisk are essential. If any is missing, TMHP returns the prior authorization request. Leaving other portions incomplete can cause the request to be pended for more information. Starred fields include the client's name, Medicaid number and date of birth, each HCPCS code and quantity, and the prescriber's NPI.
When Section A marks an item as beyond the quantity limit or as a custom item, additional documentation must support medical necessity. In Section B, every item needs a matching diagnosis and justification, and where relevant you should include height and weight, wound stage and dimensions, and functional or mobility status.