Durable Medical Equipment Waiver Rate Request Form
Submit your request for a waiver rate on durable medical equipment. Please complete all relevant fields to ensure timely processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Organization or Provider Name
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Equipment Type/Model
*
Requested Waiver Rate or Discount (%)
*
Justification for Waiver Request
*
Date of Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments (optional)
Submit Request
Should be Empty: