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This form may be used to help guide and start the process, enter as much information as possible in addition to what is required. It is HIPAA secured, but be careful, after hitting the Submit below it will clear out your information and you will lose if you did not print first. If you have a face sheet and insurance cards, have them ready when you enter the information. Follow these steps.


    1. Complete the information. Then PRINT this page (through browser, it is best to use the 3 dots on upper right of the scene).

    2. Attach to the web form with link provided; patient face sheet and copy of insurance card (front and back) by pdf file attachments.

    3. On printed form, Ensure physician live signature, blue ink is best.

    4. Fax all documents along with any additional clinical notes to (877) 969-1362. ***Secure faxline***

    5. Click SUBMIT (This will clear out information for next request.)

    6. Place page on your favorites or bookmark to your desktop for easy ordering.


We will do the work and find the right supplier for the patient. Your office may need to submit other required documentation directly to the DME, but your time is well spent from the beginning with this process. Enjoy.