Follow the steps to accurately fill out the DME form.

1. Press the ‘Get Form’ button to access the DME form and open it in a suitable editor.
2. Enter the patient’s full name in the designated field. Ensure accurate spelling to avoid any processing delays.
3. Provide the patient's address, including street, city, state, and zip code in the appropriate fields.
4. Input the patient's date of birth in the format MM/DD/YYYY in the corresponding section.
5. Fill in the patient's ID number as assigned by Virginia Premier, ensuring that the information is complete and correct.
6. Enter the telephone number where the patient can be reached. Make sure to include the area code.
7. Specify the type of equipment, supply, or appliance being requested in the provided field.
8. Describe the patient’s medical condition that justifies the need for the requested equipment. Remember to include the relevant ICD-9 code.
9. List any other treatment options that have been attempted previously to assist the patient.
10. Outline your expected goals and outcomes for the patient in relation to the requested equipment.
11. Indicate the estimated duration that the patient will require the equipment, supply, or appliance.
12. Provide the name and phone number of the preferred DME vendor in the specified fields.
13. Confirm whether the Certificate of Medical Necessity has been sent to the preferred DME provider by selecting 'Yes' or 'No'.
14. Input the name and telephone number of the ordering physician in the respective areas.
15. Complete the physician’s address in the corresponding field for accurate record-keeping.
16. Ensure the physician signs and dates the form to validate the request.
17. Review all entered information for accuracy before submitting. Save changes, download, print, or share the form as required.

Complete your Durable Medical Equipment form online to ensure a smooth authorization process.