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DME referral form - template script

A detailed written order is needed to request durable medical equipment (DME) for an injured worker.
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A detailed written order is needed to request durable medical equipment (DME) for an injured worker. The prescribing physician, nurse practitioner or physician assistant should review the content and sign and date the order. If the DME is not dispensed in the office, the order should be sent to the DMEPOS vendor to dispense the device or item as written on the script.

The following information should be included on the request:

  • Name of the injured worker, claim number and date of the order
  • Printed name and signature of the physician or practitioner
  • HCPCS code, modifier and description of the items, accessories and features
  • Diagnosis and medical necessity
  • Frequency and duration of use and specify rental versus purchase

A template referral script is available below.  


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