Forms & Documents

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information, as applicable, such as duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitation, other therapeutic interventions and results, past experience with related items, etc. For selected claims, the DME MAC, UPIC or CERT may request that the supplier obtain this information from you in order to verify that Medicare coverage criteria have been met.

NOTE TO PHYSICIANS: Diamond Medical Equipment LLC. is your partner in caring for your patient. They will not receive payment from Medicare for the items that are ordered if you do not provide information from your medical records when it is requested. Furthermore, not providing this information may result in your patients having to pay for the item themselves.

For your convenience, you may download the appropriate forms and documents below. All are Adobe PDF files.
If you are unable to open the PDF files, you can get Adobe Reader for free.

Please download, print and fill out the appropriate forms.

If you have any questions or need any assistance please call Diamond Medical Equipment Office Phone: (480)926-4363 ♦ FAX (480)926-4364