Request for Durable Medical
Equipment Services
Form Instructions: This is a fillable PDF form and can be filled out electronically utilizing Adobe Reader/Acrobat.
This form must be filled out completely. Incomplete forms may be returned to the Requester. Return this form to [email protected].
Forms will ONLY be accepted by email unless prior arrangements have been made with MRE Management.
|
Date of Request: {{DOR}} |
DOB: {{DOB}} |
|
|
Individual Name: {{FName}} {{LName}} |
Preferred Name: {{PName}} |
|
This individual has an intellectual or developmental disability as defined by the VA Code? {{IDorDD}}
Does the individual have Medicaid? {{Med}}
Medicaid Number: {{MedNum}}
Does the individual have a waiver? {{Wav}}
Waiver Type: {{WavType}}
Have you contacted your local DME for your request? {{Con}}
Company Name: {{CName}}
|
What were the barriers that hindered the DME Company from assisting you? (Please select all that apply): |
|
|
{{Barriers}} |
|
Community Service Board: {{Board}} |
|
|
Community Service Board Representative: {{CSBRep}} |
|
|
Phone Number: {{PNum}} |
Email: {{Email}} |
|
Contact Name: {{ConName}} |
|
|
Phone Number: {{PNum2}} |
Email: {{Email2}} |
Indicate individual’s type of residence: {{Residence}}
|
Name of Group Home/ICF (if applicable): {{GHName}} |
||
|
Street Address: {{Street Address}} |
Apt/Suite: {{Apt}} |
|
|
City/Town: {{City}} |
Zip Code: {{Zip}} |
|
Does the individual attend a Day Program: {{DP}}
|
Day Program Name: {{DPName}} |
||
|
Street Address: {{Street Address2}} |
||
|
City/Town: {{City2}} |
Zip Code: {{Zip2}} |
|
|
Days and Hours of Attendance: {{DnH}} |
||
SERVICE TYPE: {{Service}}
For Pressure Washing Requests Only: Do you have an outdoor spigot to accommodate? {{Spigot}}
List Equipment in need of service below:
|
Equipment Type: {{EquipType1}} |
||
|
Make/Brand Name: {{Brand1}} |
Model: {{Model1}} |
|
|
Description of Problem/Consult Needs: {{Problem1}} |
||
|
Additional Comments or Explanation of Problem if needed: {{Comments1}} |
||
List Equipment in need of service below:
|
Equipment Type: {{EquipType2}} |
||
|
Make/Brand Name: {{Brand2}} |
Model: {{Model2}} |
|
|
Description of Problem/Consult Needs: {{Problem2}} |
||
|
Additional Comments or Explanation of Problem if needed: {{Comments2}} |
||
List Equipment in need of service below:
|
Equipment Type: {{EquipType3}} |
||
|
Make/Brand Name: {{Brand3}} |
Model: {{Model3}} |
|
|
Description of Problem/Consult Needs: {{Problem3}} |
||
|
Additional Comments or Explanation of Problem if needed: {{Comments3}} |
||
List Equipment in need of service below:
|
Equipment Type: {{EquipType4}} |
||
|
Make/Brand Name: {{Brand4}} |
Model: {{Model4}} |
|
|
Description of Problem/Consult Needs: {{Problem4}} |
||
|
Additional Comments or Explanation of Problem if needed: {{Comments4}} |
||
List Equipment in need of service below:
|
Equipment Type: {{EquipType5}} |
||
|
Make/Brand Name: {{Brand5}} |
Model: {{Model5}} |
|
|
Description of Problem/Consult Needs: {{Problem5}} |
||
|
Additional Comments or Explanation of Problem if needed: {{Comments5}} |
||
Additional Comments from MRE Team if needed:
|
|
Form 101 PT/OT - 2023