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DME Product

To submit a DME Product Request, use the form below.

Required fields marked with an asterisk (*).

Representative's Name (required)

(First & Last Name)

Company Name (required)

Phone

Name of Item (required)

Only one per form

Name of Manufacturer (required)

Intended use or targeted providers (required)

Sponsoring Physicians/Providers (required)

Our Cost (We do not provide usage levels.)

CPT Code

Can it be reimbursed? (required)

Yes
No

Is there an option to have our logo on it? (required)

Yes
No

If "yes" to above, is there any additional cost? Yes
No

Recommended Reimbursement (required)

Web link to product information (required)

Pay My Bill

Refill Prescription

Request Medical Records

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