OFFICE OF MEDICAL ASSISTANCE PROGRAMS HOME HEALTH SERVICESAUTHORIZATION FOR MEDICALLY NEEDY RECIPIENTS TO RECEIVEDURABLE MEDICAL EQUIPMENT AND/OR MEDICAL SUPPLIES PATIENT222S RECIPIENT NUMBERPATIENT222S NAME - Last Name - First - Middle Initial DURABLE MEDICAL EQUIPMENT NAME OF ITEM(S) MEDICAL SUPPLIESNAME OF ITEM(S)Commonwealth of Pennsylvania � Department of Human Services � MA 312 3/19DHS COPY / FILE COPY I understand that my signature certifies that the need for the item(s) is necessary as part of the patient222s plan of care.PRESCRIBING PHYSICIAN222S NAMEDATESIGNATURE HHA REPRESENTATIVEDATE American LegalNet, Inc. www.FormsWorkFlow.com