DME Referral Form URLThis field is for validation purposes and should be left unchanged.Section 1 – Referring ProviderProvider Name(Required)Practice Name(Required)NPI Number(Required)Phone Number(Required)Fax Number(Required)Email Address Section 2 – Patient InformationPatient Name(Required)Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Insurance Name(Required)AddressMember IDMedicare NumberSection 3 – Diagnosis InformationPrimary ICD-10 Diagnosis(Required)Secondary ICD-10 DiagnosisDate Last Seen MM slash DD slash YYYY Section 4 – Equipment RequestedMobility(Required) Walker Rollator Standard Wheelchair Lightweight Wheelchair Transport Chair Cane Beds & Support Surfaces(Required) Semi-Electric Hospital Bed Full Electric Hospital Bed Mattress Overlay Pressure Relief Mattress Bathroom Safety(Required) Bedside Commode Shower Chair Transfer Bench Raised Toilet Seat Patient Lifts(Required) Hoyer Lift Sit-to-Stand Lift Other Equipment Other OtherSection 5 – Length Of NeedLength Of Need 3 Months 6 Months 12 Months Lifetime (99 Months) Section 6 – Medical NecessityPlease describe the patient's medical condition and explain why the requested equipment is medically necessary.(Required)Section 7 – Document UploadsClinical Notes(Required)Max. file size: 1 GB. Face-to-Face EvaluationMax. file size: 1 GB. Insurance InformationMax. file size: 1 GB. Additional DocumentationMax. file size: 1 GB. Section 8 – Provider CertificationConsent(Required) I certify that I have evaluated this patient and the requested equipment is medically necessary.Electronic Signature(Required)Date Signed(Required) MM slash DD slash YYYY
