Forms
For Patients:
-Equipment Orientation Checklist
-Medicare DMEPOS Supplier Standards
-Client Bill of Rights and Responsibilities
-Equipment Warranty Information
For Medical Professionals:
Mobility:
-Canes / Crutches Order Form
-Rollators Order Form
-Walkers Order Form
-Wheelchairs Order Form
Nutritional Supplements:
M-213.1 Enteral Nutrition
Providers must complete Form HFS 3701N, Questionnaire for Enteral Nutrition, along with the HFS 1409 Prior Approval Request form, for all requests for enteral nutrition products. Enteral therapy quantities should be requested in units.
All requests for oral supplements must contain the practitioner’s clinical documentation that supports the patient’s physiological inability to benefit from traditional dietary modifications. Without documentation of medical necessity for oral supplements, these are considered an item of convenience and cannot be covered.
Enteral supplies can be billed separately.
If the participant is WIC eligible, in order for HFS to consider an enteral product, the HFS 1409 Prior Approval Request must be accompanied by a WIC denial letter.