If you prefer to place your order by fax our Fax Number is as follows: 1-386-671-7422
Please review the below order form options and fill out the following required information on our order forms:
- Date and Start Date and Length of Need
- Patient Name and Address Demographics
- Patient Date of Birth
- Patient Height & Weight
- Fill Out the Appropriate Order Modality Information
- Include any insurance or testing information with your order form
- Physician Printed Name and Signature are also Required
Example of a correct order form filled out here.
After downloading the below Order Form for your patients needs; please print, complete the required information above, and fax the form to our Customer Service Department 1-386-671-7422.
Order Form Options:
- Pulse Oximetry
- Sleep Therapy – Requires Sleep Study Results
- Aerosol Therapy
- Hospital Beds & Accessories
- Bathroom Aids
- Daily Living Aids
- Enteral Nutrition
- Wound Care
New Face-to-Face Requirement for DME:
Hospital Beds, Manual Wheelchairs, Nebulizers, Oxygen, Patient Lifts, CPAP/BIPAP and many more.
For the physician prescribing a specified DME item:
- The face-to-face examination with the beneficiary must be conducted within the six (6) months prior to the date of the prescription.
- The face-to-face examination must document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.
- Remember that all Medicare coverage and documentation requirements for DMEPOS also apply. There must be sufficient medical information included in the medical record to demonstrate that the applicable coverage criteria are met. Refer to the applicable Local Coverage Determination for information about the medical necessity criteria for the item(s) being ordered.
- The prescriber must provide a copy of the face-to-face examination and the prescription for the item(s) to the DMEPOS supplier before the item can be delivered.