1. A. In addition to the HCFA 1500 Form, the completed Medical Certification Form (LDOL-WC-3002) must be submitted for all initial claims either rental or purchase.

2. B. DME 3002 Form

   							durable medical equipment certification
   this form must be completed by the physician prescribing the equipment and attached to the claim filed by the supplier
   	patient's name	age	contract no.
   	equipment prescribed	date prescribed
   	diagnosis
   	limitations (Check all conditions applicable)
   		 Weakness of arm(s)  Weakness of leg(s)  Unable to ambulate	 Confined to chair  Confined to bed  Confined to home	 Other
   	how long will the patient need this equipment (be specific)
   	if the equipment is for oxygen supplies, please provide the following information.
   	frequency of use	medical need for the equipment	expecteed benefit of receiving the oxygen therapy
   	if the equipment is for home blood glucose monitoring system, please provide the following information.
   	is the patient taking insulin?  yes  no	if yes, frequency?	degree of diabetic control?
   	ketosis?  yes  no	insulin reactions  yes  no	is patient pregnant?  yes  no
   	are other diabetic complications present (be specific)
   	physician's name address city state zip
   	physician's phone no.	physician's signature X	date

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).