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Durable Medical Forms

Effective August 1, 1996 the Health Care Finance Administration developed new Durable Medical Equipment forms. These forms serve as a vehicle for a physician or medical provider to authorize a patient to obtain certain "Durable Medical Equipment" that will be paid by Medicare. All 15 forms are available as a two part carbonless form, printed on both sides in black ink. Forms 843, 844, 846 and 847 have been revised and will be required with claims received by the DMERC.

 

 

 Hospital Bed


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 Durable Medical Equipment - Hospital Beds - 2 part forms NCR

Form # 841

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Oxygen  


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 Durable Medical Equipment - Oxygen - 2 part forms NCR

Form # 484

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Support Surfaces 


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 Durable Medical Equipment - Support Surfaces - 2 part forms NCR

Form # 842

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Motorized Wheelchair 


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 Durable Medical Equipment - Motorized Wheelchair - 2 part forms NCR

Form # 843

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Manual Wheelchairs 


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 Durable Medical Equipment - Manual Wheelchair - 2 part forms NCR

Form # 844

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Positive Airway Pressure 


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 Durable Medical Equipment - Positive Airway Pressure- 2 part forms NCR

Form # 845

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Lymphedema Pumps 


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 Durable Medical Equipment - Lymphedema Pumps - 2 part forms NCR

Form # 846

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

 FREE Shipping included on above item!!

 

 Osteogenesis Stimulators 


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 Durable Medical Equipment - Osteogenesis Stimulators- 2 part forms NCR

Form # 847

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 Trans. Electrical Nerve Stimulator 


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 Durable Medical Equipment - Trans. Electrical Nerve Stimulator - 2 part forms NCR

Form # 848

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

 FREE Shipping included on above item!!

 

 

 Seat Lift Mechanism 


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 Durable Medical Equipment - Seat Lift Mechanism - 2 part forms NCR

Form # 849

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 

 Power Operative Vehicle 


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 Durable Medical Equipment - Power Lift Vehicle- 2 part forms NCR

Form # 850

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 

 

 External Infusion Pump


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 Durable Medical Equipment - External Infusion Pump - 2 part forms NCR

Form # 851

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 

 Parental Nutrition


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 Durable Medical Equipment - Enternal Nutrition - 2 part forms NCR

Form # 853

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!

 

 

 C Continuation Form 


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 Durable Medical Equipment - Section C - Continuation Form - 2 part forms NCR

Form # 854

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Quantity Per Box:  1000 Sets

$ 79.95 per box  

FREE Shipping included on above item!!