Equipment Referral Form

Equipment Referral Form
Date

MonthDayYear
Date
Referral Source Name

First NameLast Name
Referral Source Phone Number
Please enter a valid phone number.
Referral Email
example@example.com
Referral Source Company & Town

Patient First Name (legal)
Patient Last Name
MaleFemale
Patient Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.
Aide Name or Emergency Contact
Aide or Emergency Contact Phone Number
Please enter a valid phone number.
Patient Height
Patient Weight
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Name & Phone Number
Is the patient 65 or older?

YesNo
Please ask the patient what other insurance they have. It is important that we get all insurances so that we may properly determine the patients coverage and eligiblility.

Patients over 65 will generaly always have Medicare or a Medicare replacement policy. We need that information filled out in the field below.
Medicare ID#
Arkansas Medicaid ID# or PASSE ID#
Insurance Card Upload (optional)

Cancelof
Diagnosis or conditions
**In order to qualify for incontinent supplies the patient will need a diagnosis of urinary incontinence, nocturnal enuresis, or mixed incontinence. Other qualifying conditions exist such as autism, developmental delay, cerebral palsy, ADHD, PTSD, Hirschsprung's disease, spina bifida, etc.
Equipment Requested:

Diabetic Blood Glucose Testing SuppliesBack BraceWrist BraceKnee BraceCane straight baseCane quad small baseCane quad large baseWalker wheelsWalker no wheelsRollator
Full Range Medicaid ONLY covered equipment:

DiapersPull upsBed padsUnderwear liners (panty liners)Shower Chair (not covered by Ambetter)
Comments from care provider (optional)
Use this section to inform us of sizes needed or general comments.
The referral source must thoroughly discuss the need for the requested equipment prior to completing this form. If the patient declines or you have not discussed the need for this equipment please do not fill out this form.

Confirm
Assignment of Benefits
I hereby request payment of my authorized carrier to be made on my behalf to Prestige Medical Supply Inc for current and reoccurring products and services they provide me. I further authorize a copy of this agreement to be used in place of the original and any holder of information about me is authorized to release such information to Prestige Medical Supply Inc and Health Care Finance Administration and any other insurance and/or their agents to assist in determining my benefits.

Release of Information
I hereby authorize the holder of medical or other information about me to release to the Social Security Administration, Centers for Medicare and Medicaid Services and its intermediary’s accreditation or regulatory agencies, or to any third-party payer, as required, any information needed for this or a related health claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment.

I hereby authorize and medical facility, healthcare provider or other holder of medical information pertaining to me to release this information to Prestige Medical Supply Inc or their representatives so that Prestige Medical Supply Inc is able to prepare claims for submission on my behalf to Medicare, Medicaid or other third-party payers.

Patient Responsibility
I hereby guarantee payment to Prestige Medical Supply Inc for any and all charges not covered by this assignment and waive any and all notices and demands in the event of non-payment there under. I am aware that Prestige Medical Supply Inc will bill me for all deductible and co-pay charges on all equipment and/or supplies that I have rented and/or purchased each month. I also agree that all rental equipment will be returned to Prestige Medical Supply Inc in good condition exclusive of normal wear through usage. I agree to compensate Prestige Medical Supply Inc for any loss due to misuse, lost, stolen or damaged property. I hereby certify that I have read or have had this document read to me. I understand it’s content and intent, and with my signature so execute my permission, effective as dated.

I acknowledge receiving a copy of the AHS Notice of Privacy Practices.
Change of Provider Request:

My signature below serves as my notice to cancel equipment and or supplies with your company effective immediately.

I will get all future services and supplies from:

Prestige Medical Supply (877) 472-1102
Patient Signature **This must be signed by the patient or caregiver. This form may not be signed by home health agency staff, personal care service staff, or alike. ***Please complete this form during your home visit.

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