Primos DME, Inc. Durable Medical Equipment

REFERRAL FORM

Patient Information
	Start Date	Height
	First Name	Weight
	Last Name	DOB
	Physical Address	City
	Zip	Phone


Insurance
	Insurance Type	If other please specify
	Medicare #	TX Medicaid #


Primary Physician
	Physician Name	Contact
	Address	City
	Phone2	UPIN


Dx

Equipment & Supplies
Equipment

Hospital Bed E0260 Wheel Chair Standard K0001 Wheel Chair Lightweight K0003 Wheel Chair Gel Pad E0126 Trapeze Bar Attachment E0910 Walker E0135 Walker E0148 Heavy Duty Walker w/wheels E0143 Walker w/wheels & seat E0143 & E0156 Gel Overlay Mattress E0185 Nebulizer E0570 Bedside Commode E0163 Cane E0100 Quad Cane Adjustable Height E0105 Hydraulic Pt. Lift E0630 Shower Hose/Hand Held E1399 Shower Chair E0240 Transfer Bench E0246 Blood Pressure Monitor A4670 Diabetic Supplies A4253, A4259		PLEASE LIST DESIRED ITEMS IN BOX BELOW
		Incontinence Supplies

		Underpads Female Pads Diapers Pull-ups Wipes

Has the patient received any equipment within the past 5 years? Yes No

Other Comments

	Referred By	Phone