DME Referral Form

I. Referral Source
Facility		Date of Referral
Facility Contact		Contact Phone #
Ordering Physician		Phone #
Hospital Room #

II. Patient Information
Last Name		First Name
Street Address:		City
State		Zip
Social Security #		Sex	Male Female
DOB
Caregiver Name		Caregiver Number
Primary DX		Secondary DX
Patient Height		Patient Weight

III. Insurance Information
Member Name if other than Patient
Primary Type of Insurance
Policy #		Group #
Phone #
Secondary Type of Insurance
Policy #		Group #
Phone #

IV. Equipment Information
Type of DME			Specific Information
Walker	3" Wheeled 5" Wheeled Standard Rollator
Cane	Single Point Quad-Large Base Quad-Small Base
Commodes	3 in 1 Drop Arm Extra Wide/Heavy Duty
Matress	Gel Overlay APP Low Air Loss Alternating Air
Hospital Bed	Semi-Electric Fully-Electric Full Rails 1/2 Raild Trapeze Bar
Wheelchair	Standard Lightweight Elevated Leg Rests Transport Chair Self-Propelling		Femur Length
Speciality Wheel Chair	Contact Physical Therapist Loaner Manual Wheelchair
Enternal Nutrition	Pump Gravity Bolus J-Tube PEG NGT		Formula
Oxygen	Prescription-Documentation Concentrator Portable Deliver to the Home Portable Deliver Hospital		Liters/Min RA 02 Sat
Other