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Understand what forms and documents are required for a smooth and compliant DME referral process.
Referral Form
Physician signature
Patient demographics
Diagnosis (ICD-10)
Face-to-Face Encounter
Encounter within 6 months
Clear condition & necessity
Supporting Medical Necessity
Justification for DME use
Duration of need
Ensure a smooth and compliant DME prescription process by using this quick-reference checklist before submitting documentation:
Complete Face-to-Face Encounter Notes: Include relevant medical history, physical examination findings, and the specific need for the equipment.
Detailed Written Order (DWO): Must include: patient name, item description, length of need, physician's signature and date.
Supporting Medical Documentation: Attach clinical notes that support medical necessity and diagnosis related to the requested DME.
Insurance Information: Include copies of both front and back of the patient's insurance card(s).
Physician's Contact Information: Provide up-to-date office phone, fax, and address.
Download Our Standardized Forms:
Nutritional Order Form
Manual Wheelchair
Order Form
Bracing Prescription Form
Breast Pump & Maternity Supplies Form
Clinician Medicare Checklist for DME
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