Beneficiary Information

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

Order Details

Please provide the necessary details to process the order for mobility equipment. Ensure accuracy to support CMS documentation standards.

Item(s) Ordered

Medical Necessity Documentation

Complete the following section to document the medical necessity for the mobility device(s) requested, as required by CMS guidelines. Please ensure the information provided is accurate and includes clear justification to support the patient’s need.

Medical Records Support This Necessity?

Prescribing Practitioner Information

Please provide the following information to certify the prescribing practitioner’s authorization for mobility assistive equipment (e.g., wheelchairs, walkers, or canes). Ensure all fields are completed to support compliance with CMS documentation standards.

Compliance Checklist

Complete the checklist below to verify that all required compliance steps have been followed for the provision of wheelchairs, walkers, or canes in accordance with CMS guidelines. Select all that apply and specify any additional items as needed.

Compliance Items Checklist
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