Forms & Tools
This forms library contains the forms necessary for Britkare Home Medical to dispense medical supplies to patients that are covered by Medicare and Texas Medicaid. All forms are in a PDF format and will require Adobe Reader to view and print these forms.
Click here to download Adobe Acrobat Reader
PDF forms can be printed, then mailed or faxed to:
2112 S. Coulter
Amarillo, TX 79106
Toll-Free: 800-861-9987
Phone: 806-351-2500
Fax: 806-352-0330
| Texas Medicaid | |
Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form |
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Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form |
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Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy |
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THSteps-CCP Prior Authorization Request Form |
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| Pulse Oximeter Form | |
Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form—Initial Request |
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| Medicare Forms | |
Certificate of Medical Necessity - Transcutaneous Electrical Nerve Stimulator (TENS) - DME 06.03B |
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Certificate of Medical Necessity - Seat Lift Mechanisms - DME 07.03A |
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Certificate of Medical Necessity - Oxygen DME 484.03 |
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Certificate of Medical Necessity – Enternal Feeding DME |
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Learn More About BritKare Home Medical
- Learn more about all of the services provided by BritKare Home Medical
- Access our Patient Resource Center for useful patient & caregiver information
- Learn how to contact or locate BritKare Home Medical
