Digital DME RX - Form 📋✨

Digital DME RX Request Options

Choose the best workflow for your team: visual checklist, prefilled provider review, or guided completion.
HIPAA-conscious, quick to complete, and optimized for link-based submission. Use the version that best matches your workflow.
Select a Form Version
- Daytime Garments: use for daytime compression and support.
- Daytime Garments
  
  Other
- Nighttime Garments: select items worn after hours for wash-and-wear support.
- Nighttime Garments
  
  Other
- Wraps: choose the wrap types needed for the affected area.
- Wraps
- Mastectomy Supplies: choose supplies relevant to the patient’s care plan.
- Mastectomy Supplies
- Review and confirm the prefilled information before submitting. This version is designed for providers completing orders on behalf of the physician.
- Review and Confirm
- Start with the affected area, then show only the most relevant product options for faster completion.
- Affected Area
- Step 2: select the product category that matches the area chosen above.
- Relevant Products
  
  Other
- Final step: the physician reviews, signs electronically, and confirms the date.
- Physician Signature
- Date Signed
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Staff prefill guide: build one-click links by appending patient and order data to the form URL using the field names or URL parameters supported by your workflow. Populate patient details, clinician details, and order selections in the link before sending it to providers for review and signature. This note is hidden from form fillers and is for staff reference only.
- Patient Information
- Patient Full Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Medicare Beneficiary Identifier (MBI)
- Primary Diagnosis Code (ICD-10)
- Secondary Diagnosis Code (ICD-10)
- Tertiary Diagnosis Code (ICD-10)
- Physician Information
- Physician Full Name
  
  First NameLast Name
- NPI Number
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Fax Number (optional)
  Please enter a valid phone number.Format: (000) 000-0000.
- Facility or Hospital/Clinic your Physician is Affiliated with
- Practice Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Please select a Level of Compression for the garments below:
  Insurance does not cover CCL0 garments: Explain any specifics in special notes section if need various levels
- Daytime Garments - Upper Extremity: Qty 3 every 6 months
  
  Other
- Daytime Garments - Lower Extremity: Qty 3 every 6 months
  
  Other
- Nighttime Garments - Qty of 2 for Wash & Wear
  
  Other
- Velcro/Adjustable Inelastic Wraps

Digital DME RX Request Options

Patient Information

Physician Information