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December 2016 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2 Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.11 Diabetic Equipment and Supplies : Obtaining Equipment and Supplies Through a Title XIX Form
The completed Title XIX Form must be maintained by the dispensing provider and the prescribing physician in the client’s medical record. The physician must maintain the original signed and dated copy of the Title XIX Form. The completed Title XIX Form is valid for a period up to six months from the physician’s signature date.

Texas Medicaid & Healthcare Partnership
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