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DME Order Form

You can download the PDF version of the form by clicking the download button below.

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PHONE: 718-436-6088 • FAX: 718-436-3649 • EMAIL: DMEORDERS@MEDARTS.NET
ADDRESS: 5504 13TH AVE BROOKLYN, NY 11219

You can also Fill out the form below

PATIENT INFORMATION

INSURANCE INFORMATION

MANUAL WHEELCHAIR (SEE BELOW FOR REQUIRED DOCUMENTATION)

(99=lifetime)

MOBILITY

HOSPITAL BED & SICK ROOM (SEE BELOW FOR REQUIRED DOCUMENTATION)

(99=lifetime)

BATHROOM SAFETY (Medicaid Only)

CERTIFICATE OF MEDICAL NECESSITY

WHEELCHAIR REQUIRED DOCUMENTATION

All wheelchair orders must include clinical notes documenting a  face-to-face examination conducted within the past 6 months.  The documentation must: 

  1. Confirm that the patient was evaluated specifically for  wheelchair needs. 
  2. State that the wheelchair is required for use IN THE  HOME. 
    • Per Medicare guidelines, use for outside the home  (e.g for medical appointments) does not meet coverage criteria for a wheelchair
  1. Describe the condition that necessitates a wheelchair  AND explain why a cane or walker is insufficient. 
    • Include history of condition, diagnoses, symptoms, progression and prognosis
    • Include details such as how far the patient can  ambulate with a cane or walker and why those devices do not adequately meet the patient’s mobility needs.
  1. Include physical exam relevant to mobility devices
    • Cardiopulmonary, musculoskeletal (arm and leg  strength, ROM and endurance) and neurological  (gait, balance and coordination) 
  1. Indicate the patient’s willingness to use the wheelchair  and whether the patient has the physical and mental  ability to self-propel or will have a caregiver available  to assist with the wheelchair.  

Additional required documentation for wheelchair options  and/or accessories 

  1. Lightweight Wheelchair – document that the patient  cannot self-propel a standard wheelchair but can and  does self-propel in a lightweight wheelchair. 
  2. Seat Belt – indicate the need for proper positioning  due to upper-body instability, weakness or spasticity
  3. Elevating Leg rests – Indicate the patient has edema of  extremities OR a musculoskeletal condition or brace  that prevents knee flexion OR is receiving a reclining  back wheelchair
  4. Reclining Back – indicate that the patient is unable to  perform functional weight shifts and is at high risk for  pressure ulcers OR the patient utilizes bladder  catheterization and cannot transfer to a bed.
  5. Transport Chair – elaborate as to why a standard  wheelchair is not sufficient (ease of use for outdoors,  e.g, to put in a car, is not an acceptable justification,  in-home use is the only acceptable justification). 

SUPPORT SURFACES REQUIRED DOCUMENTATION

All support surface orders must include clinical notes documenting a face-to-face examination conducted within the  past 6 months. The documentation must:  

  1. Provide a detailed description of the medical  condition requiring the support surface  
  2. Specify all applicable conditions (see criteria below)
    • Immobile OR patient has ulcers,  

 AND 

    • impaired nutritional status OR incontinence OR altered sensory impaired OR compromised circulatory status

HOSPITAL BED REQUIRED DOCUMENTATION

All hospital bed orders must include clinical notes  documenting a face-to-face examination conducted within the  past 6 months. The documentation must:  

  1. Confirm that the patient was evaluated specifically for  hospital bed needs. 
  2. Provide a detailed description of the medical  condition requiring a hospital bed, including the  necessity for positioning that cannot be achieved  with a standard bed such as  
    • Elevating the head of the bed more than 30  degrees due to CHF, CPD or aspiration risk 
    • Positioning to alleviate pain 
    • Use of traction equipment that can only be  attached to a hospital bed 
  1. Indicate the patient requires adjustable bed height to  perform transfers to a chair or a standing position
  2. Document the patient’s need for frequent and  immediate changes in body position
  3. Confirm that the patient can operate the hand control

PATIENT LIFT REQUIRED DOCUMENTATION

All patient lift orders must include clinical notes documenting a  face-to-face examination conducted within the past 6 months.  The documentation must:  

  1. Describe the medical condition requiring the patient  lift and specify that the lift is necessary to transfer the  patient between a bed, chair or commode. 

***FAX FORM TO 718-436-3649 OR SEND ELECTRONIC PRESCRIPTION DIRECTLY FROM YOUR EMR SYSTEM OR FROM PARACHUTE HEALTH***