Beneficiary Information

Please complete the required patient identification fields below. This information is essential for CMS compliance and ensuring timely DMEPOS order processing.

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Patient Name *

Medical Record Number (MRN) *

Date of Birth (DD/MM/YYYY) *

Medicare Beneficiary Identifier (MBI) *

Order Date (DD/MM/YYYY) *

Item(s) Ordered *

• Manual Wheelchair
• Power Wheelchair
• Walker
• Cane
• Accessories
• Other

If Other, please specify

Medical Necessity Justification

Quantity Ordered *

HCPCS Code (if known)

Brand/Model (if known)

Patient Diagnosis / Medical Condition *

Mobility Limitation Description

Duration of Need (in months) *

Duration of Need (in months)

• Yes
• No
• Not Sure

Physician Notes or Clinical Summary (if available)

Practitioner Name *

NPI *

Medicare (if (DD/MM/YYYY)

Signature *

Clear Signature

Date of Signature *

Compliance Items Checklist *

• SWO completed and signed prior to delivery
• Medical necessity documented in patient chart
• Face-to-Face (F2F) encounter completed within required timeframe
• Documentation supports mobility limitation affecting ADLs
• Home assessment completed and documented
• Prior authorization obtained (if applicable)
• CMN or DIF form completed (if required)
• Other

If Other, please specify

Submit