Vital Health Services – Medicare DMEPOS Standard Written Order & Medical Necessity

Vital Health Services – Medicare DMEPOS Standard Written Order & Medical Necessity

Secure professional medical order and medical-record support form for treating practitioners and facilities submitting DMEPOS orders to Vital Health Services, LLC. Use the form to enter beneficiary, practitioner, SWO, medical necessity, product-specific, and documentation details.
Beneficiary Information
Beneficiary Legal Name

First NameMiddle NameLast Name
Medicare Beneficiary Identifier (MBI)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Residential Address

Street Address

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

First NameMiddle NameLast Name
Height (inches)
Weight (lb)
Treating Practitioner Information
Treating Practitioner Name

First NameMiddle NameLast Name
Credentials
NPI
Specialty
Practice/Clinic Name
Practice Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Practice Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Secure Email
example@example.com
Office Contact Name and Phone

First NameLast Name
Order Information
Order type
Product category
CMS Standard Written Order (SWO)
Beneficiary Name

First NameMiddle NameLast Name
Medicare Beneficiary Identifier (MBI)
Order Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Item Description / Narrative
HCPCS Code
Billed Options / Accessories / Supplies
Quantity to Dispense
Treating Practitioner Signature
Medical Record Support
Diagnosis / Condition
ICD-10 Code (if known)
Onset / Duration
Current Symptoms
Severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Functional Limitations
ADLs / MRADLs Affected
Home Use Requirements
Clinical Course / Progression
Prognosis
Prior Interventions / Equipment Tried and Results
Why Alternatives Are Insufficient
Expected Benefit and Why the Type, Quantity, and Frequency Are Reasonable and Necessary
Face-to-Face and Written Order Prior to Delivery Screening
Warning: Applicable WOPD must be received before delivery and within the required period.
Is the item on a current CMS required list or a power mobility device?
If yes, explain the CMS list / power mobility device basis
Date of qualifying face-to-face encounter

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Method of face-to-face encounter
Practitioner who performed the encounter

First NameMiddle NameLast Name
Does the encounter documentation support the ordered item?
If no, explain the documentation gap
Date completed SWO was communicated to supplier

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Product-Specific Details: Urology
Catheter Type
French Size
Length
Straight or Coude
Clinical Reason for Straight or Coude Selection
Frequency per Day
Sterile Kits Required
Diagnosis and Retention Details
Self-Catheterization
Product-Specific Details: Enteral/Parenteral Nutrition
Nutrition Type
Formula or Nutrient Product
Route of Administration
Calories per Day
Containers per Day
Feeding Schedule or Method
Pump Required
Percentage of Nutrition Provided
Permanence or Impairment Description
Tube Details
Supplies Needed

Other
Product-Specific Details: Diabetes/CGM
Diabetes diagnosis
Insulin regimen

Other
Frequency of insulin administration
Problematic hypoglycemia
Problematic hypoglycemia details
Most recent relevant visit date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diabetes training completed
Current CGM system and requested receiver, sensors, transmitter, and quantities
Product-Specific Details: Mobility
MRADLs affected

Other
Home use description
Why cane or walker is insufficient
Ambulation description
Falls history
Strength and range of motion
Transfer ability
Manual wheelchair ability
Caregiver availability
Power mobility evaluation details
Accessories requested

Other
Product-Specific Details: Hospital Bed/Support Surface
Why is positioning not feasible in an ordinary bed?
Needed head elevation level
Why is frequent or immediate position change medically necessary?
Is traction required?
If traction is required, describe the clinical need and setup
Describe wounds or pressure injuries, including stage, location, and measurements
Describe mobility limitations relevant to hospital bed or support surface need
List prior support surfaces tried and the results
Product-Specific Details: PAP/Respiratory
Diagnosis / Testing Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Testing Type
Sleep Study or Oxygen Testing Details
Device and Settings
Qualifying Results
Symptoms and Prior Therapy
Accessories Requested

Other
Product-Specific Details: Orthotics/Bracing
Body location
Laterality
Diagnosis / condition
Instability / clinical findings
Device type
Expected duration of use
Expected use / wearing schedule
Product-Specific Details: Wound Supplies
Wound location / type
Wound stage / depth
Wound measurements (length × width × depth)
Drainage, treatment, and debridement details
Dressing type, change frequency, and quantity
Product-Specific Details: Other DMEPOS
Detailed Item Description
Specifications and Configuration
Medical Need and Clinical Justification
Why Alternatives Are Insufficient
Documentation Uploads
Signed Order (if separately prepared)

Cancelof
Contemporaneous Office Notes

Cancelof
Face-to-Face Note

Cancelof
Testing Results

Cancelof
Therapy or ATP Evaluation

Cancelof
Discharge Records

Cancelof
Sleep Study or Oxygen Test

Cancelof
Wound Records and Other Policy-Specific Documentation

Cancelof
Practitioner Certification and Signature
Practitioner Certification
Typed Practitioner Name

First NameMiddle NameLast Name
Electronic Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Vital Health Services – Medicare DMEPOS Standard Written Order & Medical Necessity

Beneficiary Information

Treating Practitioner Information

Order Information

CMS Standard Written Order (SWO)

Medical Record Support

Face-to-Face and Written Order Prior to Delivery Screening

Product-Specific Details: Urology

Product-Specific Details: Enteral/Parenteral Nutrition

Product-Specific Details: Diabetes/CGM

Product-Specific Details: Mobility

Product-Specific Details: Hospital Bed/Support Surface

Product-Specific Details: PAP/Respiratory

Product-Specific Details: Orthotics/Bracing

Product-Specific Details: Wound Supplies

Product-Specific Details: Other DMEPOS

Documentation Uploads

Practitioner Certification and Signature