• Vital Health Services – NC Medicaid DME Order, Medical Necessity & Prior Approval

    For North Carolina treating practitioners, case managers, and facilities to send a DME/supply order and supporting medical-necessity documentation. Requirements vary by HCPCS code and NC Medicaid clinical coverage policy; this form supports intake but does not replace an official NC Medicaid CMN/PA form when a code requires one. Do not send PHI by ordinary email. Call 911 for emergencies. Vital Health Services phone: (919) 679-3022. Fax: (888) 398-8099. Notice of Privacy Practices: https://vital-health-services-dme.fadizue.chatgpt.site/notice-of-privacy-practices.html

  • Patient Information

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Ordering Practitioner Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Order Details

  • Request Type*
  • Product Category*
  • Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical Necessity Narrative

  • Prior Approval / CMN Information

  • Requested Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Urgency of Request*
  • EPSDT Screening Required for Member Under 21?
  • Other Insurance or Medicare Coverage?
  • Last Delivery Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Discharge Date, if Applicable
     - -
    2 digit month, 2 digit day, 4 digit year

  • Urology

  • Sterile Kit Required
  • Primary Indication*
  • Ability to Self-Catheterize*
  • Latex Sensitivity

  • Incontinence

  • Patient Group*
  • Type of Incontinence*
  • Mobility Status*
  • Toileting Status*
  • Supplies Needed*
  • Garment Size
  • Absorbency Level*
  • Skin Breakdown Present*
  • Caregiver Assistance Needed*

  • Enteral / Oral Nutrition

  • Route of Nutrition*
  • Feeding Method*
  • Swallowing / Feeding Evaluation Completed*
  • Dietitian Involved

  • Diabetes / CGM

  • Diabetes type*
  • Insulin use*
  • Problematic hypoglycemia
  • Receiver needed
  • Prescriber visit date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Requested system and quantities*

  • Mobility

  • Mobility product type*
  • Which MRADLs are impaired?*
  • Where will the mobility device be used?*
  • History of falls in the past 12 months
  • Upper and lower extremity function*
    Rows
  • Transfer ability*
  • Caregiver available to assist with mobility needs*
  • Home accessibility concerns
  • Seating / accessory needs

  • Hospital Bed / Support Surface

  • Positioning need*
  • Related clinical needs
  • Frequent position changes needed
  • Wounds
  • Mobility status

  • Bathroom / Safety Equipment

  • History of Falls in Bathroom*
  • Bathroom Accessibility*

  • Orthotics / Bracing

  • Laterality*

  • Wound Supplies

  • Debridement Needed

  • Other DME

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  • Practitioner Certification and Electronic Signature

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: