Beneficiary Information

Please complete the following beneficiary information accurately. This data is required to ensure proper documentation and CMS compliance for hospital beds and bedside commodes.

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Patient Name

Medical Record Number (MRN)

Date of Birth (DD/MM/YYYY)

Medicare Beneficiary Identifier (MBI)

Medical please known)

Order Date (MM/DD/YYYY) *

Item(s) Ordered *

• Hospital Bed
• Bedside Commode
• Other

If Other, please specify

Quantity Ordered *

HCPCS Code (if known)

Brand/Model (if known)

Medical Condition Indicating Need *

Supporting Documentation in Patient Record

• Yes

Is this item part of an active care plan?

• Yes
• No

Practitioner Name *

NPI Number *

Signature *

Clear Signature

Date of Signature (DD/MM/YYYY)

Check Boxes

• SWO is on file prior to delivery
• Face-to-Face Encounter within 6 months
• Medical necessity documented in chart
• Meets CMS coverage criteria for hospital beds
• Commode requested for mobility limitation
• Other

If Other, please specify

Practitioner Signature

Clear Signature

Date of Signature (DD/MM/YYYY)

Submit