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Effective Date: 
12/2019

Documents


Instructions

Updated: 3/2019

 

Purpose

To notify a Medicaid recipient or authorized representative that proof of receipt of durable medical equipment is needed.

 

Procedure

When to Prepare

Complete this form when proof is needed that a durable medical equipment item(s) has been received by the recipient.

 

Number of Copies

An original and one copy.

 

Transmittal

The form is sent to the recipient or the recipient’s authorized representative.

 

Form Retention

Keep the copy in the case record.

 

Detailed Instructions

Name and address of recipient or authorized representative — Enter the name of the applicant or recipient and their mailing address or the name and address of the applicant or recipient's authorized representative.

Date — Self-explanatory.

Case number — Self-explanatory.

HHSC contact information — Self-explanatory.

We need proof that you received medical equipment — Self-explanatory.

We need to know if you received — Enter the item that has been requested as an incurred medical expense (IME) deduction (e.g. wheelchair). Enter enough information in this area that this form can be matched with the specific Form H1263-A, Certification of Medical Necessity – Durable Medical Equipment or Other IME, request.

Did you get the equipment? — The recipient or authorized representative completes this section.

Sign and date — The recipient or authorized representative completes this section.