Durable Medical Equipment (DME) Pre-Authorization Request Form
Patient Information
Full Name
Date of Birth
Member ID
Address
Phone
Requesting Provider Information
Provider Name
NPI Number
Facility/Practice
Phone
DME Supplier Information
Supplier Name
Phone
NPI Number
DME Requested
Description of Equipment
HCPCS Code(s)
Quantity
Medical Necessity/Clinical Information
Length of Need (months)
Insurance Information
Primary Insurance
Policy Number
Secondary Insurance
Policy Number
Additional Notes
Requesting Provider Signature
Date