DME Prior Authorization Request Form
Submit your durable medical equipment prior authorization request using the DME Prior Authorization Request Form.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member Reference Number
*
Requesting Provider Name
*
Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Organization/Clinic
*
Equipment Requested
*
Please Select
Wheelchair
Walker
Hospital Bed
Oxygen Equipment
CPAP Machine
Other
Diagnosis or Clinical Reason for Request
*
Medical Necessity Details
*
Requested Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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