Vital Health Services – Provider Referral & DME Order

Vital Health Services – Provider Referral & DME Order

Please use this secure form to submit referral and DME orders. Do not send PHI by ordinary email.
Patient & Referral Details
Referral Type
Product Category
Patient Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex as Listed with Insurer

Other
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Patient Phone
Please enter a valid phone number.Format: (000) 000-0000.
Representative / Caregiver Name

First NameMiddle NameLast Name
Primary Insurance Member ID
Secondary Insurance Member ID
Primary Insurance Provider
Secondary Insurance Provider
Upload Insurance Cards

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Ordering Practitioner & Facility Information
Ordering practitioner full name

First NameMiddle NameLast Name
Credentials
Individual NPI
Taxonomy / specialty
Practice / facility name
Practice / facility address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Office phone and fax
Please enter a valid phone number.Format: (000) 000-0000.
Secure email
example@example.com
Contact person

First NameMiddle NameLast Name
Clinical Basis for Order
Date of face-to-face or qualifying evaluation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diagnosis code(s) and descriptions
Prognosis / duration of need
Clinical narrative / functional limitation
Chart note upload

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Signed prescription / order upload

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Urology Supplies (Conditional)
Supply Type

Other
HCPCS Code
Manufacturer / Model
French Size
Length
Tip Type
Lubrication / Kit Features

Other
Quantity Per Day
Quantity Per Month
Refills
Length of Need
Diagnosis
Can the patient self-catheterize?
Medical Necessity Narrative
Urology Item Details
Incontinence Supplies (Conditional)
Notice of Privacy Practices: https://vital-health-services-dme.fadizue.chatgpt.site/notice-of-privacy-practices.html
Incontinence product types

Other
Patient group
Size
Measurements or fit details
Units per day
Units per month
Primary incontinence type
Underlying diagnosis causing incontinence
Mobility and toileting ability
Caregiver assistance needed
Medical-necessity narrative
Nutrition Supplies (Conditional)
Warning: Parenteral nutrition may require specialty coordination.
Nutrition supply type
Formula or product name
HCPCS code
Product number
Route

Other
Calories per unit
Units per day
Units per month
Total daily calories
Percent of nutrition supplied
Administration method

Other
Pump and supply needs

Other
Diagnosis
Reason patient cannot maintain nutrition with ordinary food or modified diet
Height
Weight
Weight history
BMI
Relevant labs or assessment findings
Swallowing or gastrointestinal impairment details
Dietitian assessment
Length of need
Refills
Substitutions allowed
Allergies or intolerances
Upload LMN

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Upload nutrition evaluation

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Upload growth chart

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Upload swallow study

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Upload operative report

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Upload clinical notes

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General DME (Conditional)
Requested item(s)

Other
HCPCS code
Detailed item description and accessories
Quantity
Frequency of use
Length of need
Order type
Diagnosis and functional limitation
Activities of daily living affected

Other
Why lesser equipment is insufficient
Will the item be used in the home?
Height
Weight
Current equipment and reason for replacement
Face-to-face evaluation date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical-necessity narrative
Supporting Documents & Certification
Supporting documents included
Provider attestation and certification
Provider typed name

First NameMiddle NameLast Name
Credentials
Individual NPI
Electronic signature
Signed date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred secure follow-up method
Should be Empty:

Vital Health Services – Provider Referral & DME Order

Patient & Referral Details

Ordering Practitioner & Facility Information

Clinical Basis for Order

Urology Supplies (Conditional)

Incontinence Supplies (Conditional)

Nutrition Supplies (Conditional)

General DME (Conditional)

Supporting Documents & Certification