Workers' Compensation DME Referral Form

Optimize your workers' compensation Durable Medical Equipment (DME) referral process with our comprehensive and easy-to-use form. Designed specifically for healthcare providers and medical supply companies, this form streamlines the authorization and delivery of essential medical equipment for injured workers.

Why Use Our Workers' Compensation DME Form?

• Simplified Documentation: Capture all necessary patient, injury, and insurance details in one place.

• Accurate Claims Processing: Ensure all workers' compensation claim information is clearly documented to avoid delays.

• Comprehensive Equipment Options: Easily specify the required DME, including wheelchairs, walkers, hospital beds, and more.

• Efficient Delivery Instructions: Choose between shipping to the patient or pick-up at the provider location with preferred delivery dates.

How to Use This Form

1. Fill out patient information including contact details and injury specifics.

2. Provide workers' compensation claim details such as claim number and insurance carrier.

3. Enter prescribing physician information for authorization.

4. Select the required DME supplies from the checklist.

5. Specify delivery preferences and authorize the request with a signature.

Streamline your workers' compensation medical equipment referrals today with this user-friendly form, designed to reduce paperwork and speed up patient care.

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