36C10G20R0014-010.docx
DOCX document Posted
- Solicitation number
- 36C10G20R0014
About this file
This document contains a pre-solicitation notice and request form for durable medical equipment and prosthetic items through the Department of Veterans Affairs Community Care Network program. The notice announces the intent to issue a request for proposal for a single-award indefinite delivery indefinite quantity contract to establish and maintain a provider network throughout Alaska. The contractor will be responsible for customer service, quality monitoring and improvement, utilization of data and metrics, and claims processing and payment for services ordered under the contract. The anticipated period of performance is a 9-month base period with seven 1-year options. The request form requires providers to submit prescriptions and documentation for durable medical equipment, medical devices, orthotics, and prosthetics through the VA medical center of jurisdiction for veterans. Information such as patient details, diagnosis codes, item descriptions, medical justification, and expected delivery details must be provided.
36C10G20R0014 CCN Region 5 Attachment N VHA Request Form for CCN DME Med Dev Orthotic and Prosthetic Items.docx
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Text version
Veterans Health Administration Request Form for CCN DME, Medical Devices, Orthotic, and Prosthetic Items All Durable Medical Equipment (DME), medical devices, orthotic and prosthetic item prescriptions must be faxed (or mailed) to the VA Medical Center (VAMC) of jurisdiction or submitted through the VA Community Care Provider Portal. Please address all correspondence to: Attention Chief of Prosthetics or Prosthetics CCN POC.
* FOR URGENT REQUESTS, PLEASE CALL THE MAIN CCN POINT OF CONTACT AT THE VA MEDICAL CENTER OF
JURISDICTION FOR COORDINATION
Date of Request:
| Fax number (Prosthetic Service, VAMC of Jurisdiction): |
| Mailing Address (Prosthetic Service, VAMC of Jurisdiction): |
| Patient's Full Name: |
| Approved Referral Number: |
| Patient's Date of Birth: |
| Prescribing Provide's Name: |
| Patient's Last 4 Digits of SSN: |
| Prescribing Provider's Fax Number: |
| Patient's EDIPI: |
| Prescribing Provider's Phone Number: |
| ICD-10 Code(s) and Diagnosis: |
| Prescribing Provider's Office Address: |
Description and HCPCS Code for Each Prescribed Item: If a specific brand, model or product is prescribed, include brand/vendor, make, model, and part number for prescribing a specific brand, model or product.
Medical Justification:
Patient Education (indicate):
Patient education was completed or item to be mailed for education to be provided
Prescribing Provider's Signature:
| Additional Notes for This Prescription: |
| Expected Item(s) Delivery Date and Location (Address): |
Person Filling Out This Form & Contact Number:
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