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 MRETeam@dbhds.virginia.gov.

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}}

 

REQUESTOR INFORMATION 

Community Service Board: {{Board}}

Community Service Board Representative: {{CSBRep}}

Phone Number: {{PNum}}

Email:  {{Email}}

 

SCHEDULING CONTACT INFORMATION 

Contact Name: {{CName}}

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}}

 

DAY SUPPORT INFORMATION 

Does the individual attend a Day Program: {{DP}}

Day Program Name: {{DPName}}

Street Address: {{Street Address2}}

City/Town: {{City}}

Zip Code: {{Zip}}

 Form 101 PT/OT - 2023