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To submit a DME Product Request, use the form below.
Representative's Name
(First & Last Name)
Company Name
Phone
Email
Name of Item
Only one per form
Name of Manufacturer
Intended use or targeted providers
Sponsoring Physicians/Providers
Our Cost (We do not provide usage levels.)
CPT Tode
Can it be reimbursed?
Yes
No
Is there an option to have our logo on it?
Yes
No
If "yes" to above, is there any additional cost?
Yes
No
Recommended Reimbursement
Web link to product information
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