Resources

<div class="page-content">
<p>Request to MSO for Credentialing and Re Credentialing Non Par <a href="https://cms.gotecq.net/assets/f3ad3ce9-f2d8-405a-b488-99fdac6a74a2">[ pdf ]</a></p>
<div class="document"><iframe style="width: 100%; min-height: 720px;" src="https://cms.gotecq.net/assets/f3ad3ce9-f2d8-405a-b488-99fdac6a74a2" frameborder="0"></iframe></div>
<p>Request to MSO for Credentialing and Re Credentialing Par 2 <a href="https://cms.gotecq.net/assets/ebd76c6b-dde2-4aa0-a8c7-9621005e209f">[ pdf ]</a></p>
<div class="document"><iframe style="width: 100%; min-height: 720px;" src="https://cms.gotecq.net/assets/ebd76c6b-dde2-4aa0-a8c7-9621005e209f" frameborder="0"></iframe></div>
<p>Van Lang IPA Request for Application 1563451567503 rev3 1564134456837 <a href="https://cms.gotecq.net/assets/a3d6e42d-8761-41dd-b75c-872fd43cb8a4">[ pdf ]</a></p>
<div class="document"><iframe style="width: 100%; min-height: 720px;" src="https://cms.gotecq.net/assets/a3d6e42d-8761-41dd-b75c-872fd43cb8a4" frameborder="0"></iframe></div>
</div>

Request to MSO for Credentialing and Re Credentialing for Non Par and Par

5c529ec6 970e 4a99 9bb3 C8f1aa303d3e

Provider Network Operations

Amerivantage Dual 2018 [[ PDF ]](https://cms.gotecq.net/assets/6eaa1730-7a3b-4fd9-b798-6de021676e4b)

[![Amerivantage Dual 2018](https://cms.gotecq.net/assets/8dcb42a8-4ccd-4735-ab45-d1a231cd4f72)](https://cms.gotecq.net/assets/6eaa1730-7a3b-4fd9-b798-6de021676e4b)

Van Lang IPA, an independent physician association founded by primary care physicians, is a physician led organization. We engage with high quality primary care physicians, specialists, hospital systems and ancillary services that share our mission to provide superior care through innovation, technology and collaboration.

Man 791049 1920

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs)

Amerigroup Classic 2016 Formulary [[ PDF ]](https://cms.gotecq.net/assets/badc5954-dfb0-4d24-90fc-6e22e528cb4a)

[![Amerigroup Classic 2016 Formulary](https://cms.gotecq.net/assets/ef4deecd-9e8d-44a5-b780-11ff96cb0026)](https://cms.gotecq.net/assets/badc5954-dfb0-4d24-90fc-6e22e528cb4a)


This formulary was updated on November 1, 2017. For more recent information or other questions, please contact Amerivantage Classic (HMO) Customer Service, at 1-866-805-4589 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30.

Amerivantage Classic (HMO) 2016 Formulary (List of Covered Drugs)

Dme Noridian Provider Education 4 2017 [[ PDF ]](https://cms.gotecq.net/assets/c49cb5c5-45f9-489b-a287-5ea8d24a3ac0)

[![](https://cms.gotecq.net/assets/22850501-7e5e-4a5e-b272-14168602696b)](https://cms.gotecq.net/assets/c49cb5c5-45f9-489b-a287-5ea8d24a3ac0)

Therapeutic Shoes for Persons with Diabetes

Amerigroup Specialty 2016 Formulary [[ PDF ]](https://cms.gotecq.net/assets/bfd8eefb-08bf-4c1f-b97e-31e768f7fbf3)

[![Amerigroup Specialty 2016 Formulary](https://cms.gotecq.net/assets/d83c7c87-ed4d-44e0-ab8d-ca9f8f0dcda4)](https://cms.gotecq.net/assets/bfd8eefb-08bf-4c1f-b97e-31e768f7fbf3)


Amerivantage Select (HMO) 2016

Amerigroup Select 2016 Formulary [[ PDF ]](https://cms.gotecq.net/assets/bfd8eefb-08bf-4c1f-b97e-31e768f7fbf3)

[![Amerigroup Select 2016 Formulary](https://cms.gotecq.net/assets/d83c7c87-ed4d-44e0-ab8d-ca9f8f0dcda4)](https://cms.gotecq.net/assets/bfd8eefb-08bf-4c1f-b97e-31e768f7fbf3)


Amerivantage Select (HMO) 2016 Formulary (List of Covered Drugs)

2017 Benefits Specialty [[ PDF ]](https://cms.gotecq.net/assets/60b43409-707f-4726-9002-ca83d5ea8356)

[![](https://cms.gotecq.net/assets/788a5ae4-8549-4a75-a8e8-7405dbdae084)](https://cms.gotecq.net/assets/60b43409-707f-4726-9002-ca83d5ea8356)

Summary of Benefits for Amerivantage Dual Coordination (HMO SNP)

2017 Benefits Select And Classic [[ PDF ]](https://cms.gotecq.net/assets/23a73328-e5bb-4507-8f39-269f160f348d)

[![](https://cms.gotecq.net/assets/e949b4c0-0004-4a95-a49e-cda2c29ecd6f)](https://cms.gotecq.net/assets/23a73328-e5bb-4507-8f39-269f160f348d)


Summary of Benefits for Amerivantage Classic (HMO) and Amerivantage Select (HMO)

Amerigroup Otc Catalog 2017 [[ PDF ]](https://cms.gotecq.net/assets/c25fe233-87b8-4ab7-a216-00746332735b)

[![Amerigroup Otc Catalog 2017](https://cms.gotecq.net/assets/11e49258-979a-4f6b-92ab-6457d402e554)](https://cms.gotecq.net/assets/c25fe233-87b8-4ab7-a216-00746332735b)


2017 Over-the-Counter Health Products Catalog

Baa Electronic Data Exhange Vlipa [[ PDF ]](https://cms.gotecq.net/assets/cecc8054-da6b-475c-be3c-fc2c170b1822)

[![Baa Electronic Data Exhange Vlipa](https://cms.gotecq.net/assets/bd942c65-88cb-4d71-bbb4-cea0914965c6)](https://cms.gotecq.net/assets/cecc8054-da6b-475c-be3c-fc2c170b1822)

(Credentialing) Business Associate Agreement

Amerivantage Classic 2018 [[ PDF ]](https://cms.gotecq.net/assets/1a87f808-2c7f-4e07-93b2-c787b46b6263)

[![Amerivantage Classic 2018](https://cms.gotecq.net/assets/bf9f55c9-ae50-4683-9ea9-d3e0f0bcee63)](https://cms.gotecq.net/assets/1a87f808-2c7f-4e07-93b2-c787b46b6263)

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs)

Texas Standard Credentialing Application [[ PDF ]](https://cms.gotecq.net/assets/b80a4dd7-5f4c-4288-94ba-6c18369a8f5d)

[![](https://cms.gotecq.net/assets/384d0671-2397-48b6-bb07-aa87f497ca95)](https://cms.gotecq.net/assets/b80a4dd7-5f4c-4288-94ba-6c18369a8f5d)


(Credentialing) Texas Standard Credentialing

2017 Amerivantage Classic [[ PDF ]](https://cms.gotecq.net/assets/dcb81622-4da3-4e6f-86f1-067a741afd08)

[![](https://cms.gotecq.net/assets/75a7d84f-50dc-4832-bc12-f4a2da10c3b6)](https://cms.gotecq.net/assets/dcb81622-4da3-4e6f-86f1-067a741afd08)

This formulary was updated on November 1, 2017. For more recent information or other questions, please contact Amerivantage Classic (HMO) Customer Service, at 1-866-805-4589 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30., or visit

Amerivantage Classic (HMO) 2017 Formulary (List of Covered Drugs)



* Transportation
* Hearing aids
* Dentistry
* Gym & Fitness Program

1. Transportation benefits
--------------------------

**Reservations line:** Members should call this number to schedule their trips, at least 48 hours in advance.

Reservations: 844-287-6695 (Xin gọi số này để lấy hẹn)

**Ride Assist:** Members should call this number when waiting for a pick up or when they have finished their appointment and are ready to be picked up for their return trip.

Ride Assist: 844-287-6696 (Call this number after you have seen the Doctor & ready to go home -- Xin gọi số này sau khi gặp bác sĩ để lấy xe đi về)

#### For Vietnamese Assistance


**Phone:** 281-507-3321

**Email:** [Phuong.Tran@amerigroup.com](mailto:Phuong.Tran@amerigroup.com)


Transportation Benefits [[ PDF ]](https://cms.gotecq.net/assets/c1abce2d-2be2-48fe-88a2-66c7a6774631)

[![](https://cms.gotecq.net/assets/d9b4881d-6b3a-421a-9e93-0cf8a52fa6c5)](https://cms.gotecq.net/assets/c1abce2d-2be2-48fe-88a2-66c7a6774631)


2. Hearing Aid Benefits
-----------------------

for Van Lang IPA eligible members: Classic, Select, Specialty

Covered up to $3,000 for hearing aids and supplies every year.

### CALL 1-866-344-7756


![Hearing Aids Benefits](https://cms.gotecq.net/assets/53c7d26c-7a67-40d7-a2db-321826f11b29)

Hearing Aids Benefits [[ PDF ]](https://cms.gotecq.net/assets/51040eb3-0c08-48bd-9fc1-46f38c5b2762).

[![](https://cms.gotecq.net/assets/85614b5d-c79a-40d6-8d33-d898aed2cbde)](https://cms.gotecq.net/assets/51040eb3-0c08-48bd-9fc1-46f38c5b2762)

3. Dental services
------------------

To find a dentist, please click the following link:

<https://govservices.dentaquest.com/Router.jsp?component=Main&source=Logon&action=ProviderDirectory2>

4. Gym & Fitness Program Benefits
---------------------------------

Participate in a Fitness Program / GYM: **You Pay Nothing**

To find a Silver Sneaker Location: <https://tools.silversneakers.com/LocationSearch>


Silver Sneaker Brochure [[ PDF ]](https://cms.gotecq.net/assets/a1113a9f-87aa-4b3f-884a-8d8349e96379)

[![](https://cms.gotecq.net/assets/2256865e-39d8-4ff8-88da-171c8d08a1e1)](https://cms.gotecq.net/assets/a1113a9f-87aa-4b3f-884a-8d8349e96379)


Benefits information for Amerigroup/Van Lang IPA members

2017 Amerivantage Specialty [[ PDF ]](https://cms.gotecq.net/assets/dcb81622-4da3-4e6f-86f1-067a741afd08)

[![2017 Amerivantage Specialty](https://cms.gotecq.net/assets/75a7d84f-50dc-4832-bc12-f4a2da10c3b6)](https://cms.gotecq.net/assets/dcb81622-4da3-4e6f-86f1-067a741afd08)

Amerivantage Dual Coordination (HMO SNP) 2017 Formulary (List of Covered Drugs)

Practitioner Rights Notice   Texas App [[ PDF ]](https://cms.gotecq.net/assets/eec87cb8-7207-4224-9a7d-8cedaf2931a5)

[![](https://cms.gotecq.net/assets/8e4897f6-01fd-4529-8da4-814e13c5fae1)](https://cms.gotecq.net/assets/eec87cb8-7207-4224-9a7d-8cedaf2931a5)


(Credentialing) Practitioner Rights Notice

Amerigroup Benefits Specialty 2016 [[ PDF ]](https://cms.gotecq.net/assets/e79e2ed5-d19a-412c-b463-03fc99be05bc)

[![](https://cms.gotecq.net/assets/1f4844da-af9d-4fb8-a037-cdfe0e91e7b1)](https://cms.gotecq.net/assets/e79e2ed5-d19a-412c-b463-03fc99be05bc)

Amerigroup Drug Alternatives [[ PDF ]](https://cms.gotecq.net/assets/f173e669-6f37-4b27-b913-1d81a8aa0ba6)

[![](https://cms.gotecq.net/assets/fdfd8cd4-4eab-4de2-aac4-0cc5628ecdbb)](https://cms.gotecq.net/assets/f173e669-6f37-4b27-b913-1d81a8aa0ba6)

Amerigroup Drug Alternatives

Request to MSO for Credentialing and Re Credentialing Non Par [[ PDF ]](https://cms.gotecq.net/assets/88f384d2-b76c-424b-b50b-1eb4e8bf25be)

[![](https://cms.gotecq.net/assets/6083bdc5-0ad6-41ab-9d07-88dc8923ff05)](https://cms.gotecq.net/assets/88f384d2-b76c-424b-b50b-1eb4e8bf25be)



Request to MSO for Credentialing and Re Credentialing Par 2  [[ PDF ]](https://cms.gotecq.net/assets/face89ee-b0e8-4ab0-af5b-a569535c3c4c)

[![](https://cms.gotecq.net/assets/92296ec3-3ee4-4c64-8987-89f352e550aa)](https://cms.gotecq.net/assets/face89ee-b0e8-4ab0-af5b-a569535c3c4c)


Van Lang IPA Request for Application 1563451567503 rev3 1564134456837  [[ PDF ]](https://cms.gotecq.net/assets/54418913-57dc-429f-8525-0c80675fc9bf)

[![](https://cms.gotecq.net/assets/94374c6f-8735-48c2-be1e-e6bd9553c7f7)](https://cms.gotecq.net/assets/54418913-57dc-429f-8525-0c80675fc9bf)


Mso Raf Score Timeline [[ PDF ]](https://cms.gotecq.net/assets/a88868cf-bbe3-4a0b-a8ea-67de31d806a0)

[![](https://cms.gotecq.net/assets/3803d2c8-d088-477c-afb9-b2b32831a77a)](https://cms.gotecq.net/assets/a88868cf-bbe3-4a0b-a8ea-67de31d806a0)


HEDIS Score Timeline

2016 0721 Preferred Drug List [[ PDF ]](https://cms.gotecq.net/assets/8941bf77-a996-4ce1-b800-1f77a3630ec5)

[![](https://cms.gotecq.net/assets/9232765f-bc90-4ba6-9808-58056e610182)](https://cms.gotecq.net/assets/8941bf77-a996-4ce1-b800-1f77a3630ec5)

Medicaid Preferred Drug List (July 2016)

Dm Supplies Coverage Amerigroup 2017 [[ PDF ]](https://cms.gotecq.net/assets/779dfa9a-195f-4b90-adce-5959207db6eb)

[![](https://cms.gotecq.net/assets/86b53489-eb72-4962-a51f-571b8ab40ee9)](https://cms.gotecq.net/assets/779dfa9a-195f-4b90-adce-5959207db6eb)


IMPORTANT: 2017 Coverage Changes for Diabetic Supplies

An **advance directive** is a legal document that tells your family, friends and healthcare professionals the care you would like to have if you become unable to make medical decisions. Through advance directives, you can make legally valid decisions about your future medical treatment.

You do not need a lawyer to complete your advance directives. However, you should be aware that each state has its own laws for creating advance directives.

There are three advance directives recognized in Texas:


* The **Texas Medical Power of Attorney** appoints someone to speak for you any time you are unable to make your own medical decisions, not only at the end of life. Your attending physician must certify in writing that you are unable to make health care decisions and file the certification in your medical record.


Medical Power Of Attorney ( English ) [[ PDF ]](https://cms.gotecq.net/assets/143aa9c4-fc85-460e-9891-6f5314fd7b78)

Medical Power Of Attorney ( Spanish ) [[ PDF ]](https://cms.gotecq.net/assets/e0cbf375-3914-409e-be9e-f9310dba41a4)

* A **living will**, officially known in Texas as the Directive to Physicians and Family or Surrogates, describes the kind of medical treatments or life-sustaining treatments you would want if you were seriously or terminally ill. A living will should be signed, dated and witnessed by two people, preferably individuals who know you well but are not related to you and are not your potential heirs or your health care providers.


Directive To Physicians ( English ) [[ PDF ]](https://cms.gotecq.net/assets/a0038bdd-8881-481d-bbe8-e1231735762e)

Directive To Physicians ( Spanish ) [[ PDF ]](https://cms.gotecq.net/assets/59d2ef5a-132e-4805-9038-52ccf35212ed)

* The **Out-of-Hospital Do Not Resuscitate (DNR) order** provides you with the right to withhold or withdraw cardiopulmonary resuscitation (CPR) or other treatments such as defibrillation and artificial ventilation.


Out Oh Hospital Do Not Resuscitate ( English ) [[ PDF ]](https://cms.gotecq.net/assets/b5fb04f5-94fd-4f17-92d2-dad2c1d51d76)

Out Oh Hospital Do Not Resuscitate ( Spanish ) [[ PDF ]](https://cms.gotecq.net/assets/c7729a51-c545-498b-90ab-ac75d206c589)

By creating an advance directive, you are making your preferences about medical care known before you're faced with a serious injury or illness. This will spare your loved ones the stress of making decisions about your care while you are sick. Any person 18 years of age or older can prepare an advance directive.

In order to make your directive legally binding, you must sign it, or direct another to sign it, in the presence of two witnesses who must also sign the document.


Advance Directives

2017 Amerivantage Select [[ PDF ]](https://cms.gotecq.net/assets/1ee64e8d-23f2-475c-83c7-2b0ded453805)

[![2017 Amerivantage Select](https://cms.gotecq.net/assets/19e0a1db-c7e7-4f37-abca-93e27187cb77)](https://cms.gotecq.net/assets/1ee64e8d-23f2-475c-83c7-2b0ded453805)

Amerivantage Select (HMO) 2017 Formulary (List of Covered Drugs)

General Documentation Requirements Online Version [[ PDF ]](https://cms.gotecq.net/assets/b30d15a4-e68e-45da-97c3-e15679ab31ea)

[![](https://cms.gotecq.net/assets/8bfd4714-3316-4fc0-985c-5a9936c0c01b)](https://cms.gotecq.net/assets/b30d15a4-e68e-45da-97c3-e15679ab31ea)


General Documentation Requirements Print Version [[ PDF ]](https://cms.gotecq.net/assets/4e316884-5f00-4add-8f1d-5a837da58ad0)

[![](https://cms.gotecq.net/assets/6e5fec50-299b-408b-98f3-6c3c20f9fa22)](https://cms.gotecq.net/assets/4e316884-5f00-4add-8f1d-5a837da58ad0)


General Documentation Checklists

Dm Shoes Certifyingphysiciantherapeuticshoesrevised2007 [[ PDF ]](https://cms.gotecq.net/assets/20bf21c8-7f69-4167-9514-bf93a9fe9605)

Noridian Provider Education 4 2017 [[ PDF ]](https://cms.gotecq.net/assets/80850936-4721-46b3-bfd0-6842736c0228)
### Ankle & Knee


Ankle Foot Knee Ankle Foot Orthoses [[ PDF ]](https://cms.gotecq.net/assets/2302bd0c-656d-4269-bf89-17af79fd4a34)

Knee Orthoses [[ PDF ]](https://cms.gotecq.net/assets/6226dc35-36b4-4e9e-a01c-fc4bfc528823)
### Wheelchair, canes & walkers (motion support)


Canes And Crutches [[ PDF ]](https://cms.gotecq.net/assets/11178e6a-88a7-44f4-9051-b9af558116b6)

Lower Limb Prostheses [[ PDF ]](https://cms.gotecq.net/assets/89c23955-a80f-4781-a0fe-8a8f19c4aca1)

Manual Wheelchairs [[ PDF ]](https://cms.gotecq.net/assets/bddff839-fae0-4e54-a728-7c685d9e5f7a)

Patient Lifts [[ PDF ]](https://cms.gotecq.net/assets/5c540479-faa7-4b4d-bed5-64a545c2dcf1)

Group 1 And Group 2 No Power Option Pwcs And Custom Pwcs [[ PDF ]](https://cms.gotecq.net/assets/52f27d21-f7ab-47f8-8975-b78fdb29db03)

Group 2 Single And Multiple Power Option Wheelchairs [[ PDF ]](https://cms.gotecq.net/assets/746e430c-840e-4a95-a505-d18ebe73cf9f)

Group 3 No Power Option Wheelchairs [[ PDF ]](https://cms.gotecq.net/assets/5f666f0f-2411-48cc-a90b-47232dc0d8a9)

Dme Noridian Provider Education 4 2017 [[ PDF ]](https://cms.gotecq.net/assets/3b3bbd38-1ad3-4ee7-9cf4-4a9a6ea35dc8)

Walkers Checklist [[ PDF ]](https://cms.gotecq.net/assets/bd3c8a91-a4e9-489a-82bf-05a75e83d112)
### Support surfaces


Pressure Reducing Support Surfaces Prss Group1 [[ PDF ]](https://cms.gotecq.net/assets/4c664864-859e-488b-9cb7-ece452e29aaf)

Pressure Reducing Support Surfaces Prss Group 2 [[ PDF ]](https://cms.gotecq.net/assets/df219555-194c-48ec-bd19-274713e18d1f)

Pressure Reducing Support Surfaces Prss Group 3 [[ PDF ]](https://cms.gotecq.net/assets/2c5a83c2-cb1c-42a4-a077-51b498504d97)
### Nutrition


Enteral Nutrition [[ PDF ]](https://cms.gotecq.net/assets/bc5f60e9-f0aa-4bfd-a650-9ac10eb9fb46)

Parenteral Nutrition [[ PDF ]](https://cms.gotecq.net/assets/39df8960-2378-4c18-9fa0-42c2e556e636)
### Other


Automatic External Defibrillators [[ PDF ]](https://cms.gotecq.net/assets/e9e7642f-e226-4496-b8bf-9db03d344785)

External Breast Prostheses [[ PDF ]](https://cms.gotecq.net/assets/32653d70-ec3a-4fdb-a185-272f0c917091)

External Infusion Pumps [[ PDF ]](https://cms.gotecq.net/assets/0dad41f3-26e7-4e92-9a9a-21852a90c343)

Glucose Monitors And Related Supplies [[ PDF ]](https://cms.gotecq.net/assets/392b6a7a-4db3-4825-a252-121d2b1226cd)

Hospital Beds And Accessories [[ PDF ]](https://cms.gotecq.net/assets/3634fb27-1e64-4c53-9ae0-ae3655d81bd1)

Immunosuppressive Drugs [[ PDF ]](https://cms.gotecq.net/assets/d763f2fd-7946-4a20-9597-c07c755bceb7)

Nebulizers [[ PDF ]](https://cms.gotecq.net/assets/6933ab4e-5042-42b6-aa1e-49d97fc6a4e7)

Negative Pressure Wound Therapy Npwt Pumps [[ PDF ]](https://cms.gotecq.net/assets/e256958f-c610-46e9-a671-3c815edce145)

Oral Anticancer Drugs [[ PDF ]](https://cms.gotecq.net/assets/30f4aab2-5808-4f5f-8a2a-1c72948fb7fb)

Osteogenesis Stimulators [[ PDF ]](https://cms.gotecq.net/assets/11bc32ec-bc36-47e9-acc4-06a30f5aca00)

Ostomy Supplies [[ PDF ]](https://cms.gotecq.net/assets/0c59347c-b013-4565-b7e7-da766d282b43)

Oxygen And Oxygen Equipment [[ PDF ]](https://cms.gotecq.net/assets/b5f1104c-ac8f-4f59-8c1d-d3f15ececb91)

Power Operated Vehicles And Push Rims Activated Power Assist Devices [[ PDF ]](https://cms.gotecq.net/assets/737b337c-6b77-4bfb-bc44-f987d55e0f93)

Pap Overhaul Checklist [[ PDF ]](https://cms.gotecq.net/assets/3650df47-a90b-4ea5-a1c6-0c7c7bf9ae40)

Refractive Lenses [[ PDF ]](https://cms.gotecq.net/assets/074a4228-df57-4720-b152-1bb8caa60eb8)

Respiratory Assist Devices Checklist [[ PDF ]](https://cms.gotecq.net/assets/d8188276-b641-4014-b433-eb9d411dfca0)

Spinal Orthoses [[ PDF ]](https://cms.gotecq.net/assets/d316635a-c544-44e3-9fc1-b6c5ab5d95a3)

Suction Pumps Checklist [[ PDF ]](https://cms.gotecq.net/assets/56b50112-c4cf-4fad-80ca-4dcb8556df69)

Therapuetic Shoes Checklist [[ PDF ]](https://cms.gotecq.net/assets/cafbd8a9-0505-47fe-ba49-8eafc8dc81a7)

Tracheostomy Care Checklist [[ PDF ]](https://cms.gotecq.net/assets/fb6180a7-e98c-4ea0-b9ba-3080fe1c76a8)

Transcutaneous Electrical Nerve Stimulators Checklist [[ PDF ]](https://cms.gotecq.net/assets/ec9ff87d-4b7c-4e9b-a5b8-4f038b0560b8)

Urological Supplies Checklist [[ PDF ]](https://cms.gotecq.net/assets/1b18452d-6779-4297-b4d5-869bd4bca614)


Specialty Documentation Checklists

20190208dmef2f_requirements_highcostdme [[ PDF ]](https://cms.gotecq.net/assets/52567683-d9a8-4f9d-b2b4-5916b4976640)

[![](https://cms.gotecq.net/assets/52567683-d9a8-4f9d-b2b4-5916b4976640)](https://cms.gotecq.net/assets/52567683-d9a8-4f9d-b2b4-5916b4976640)

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