Medical Equipment Request Form Template

Simplify durable medical equipment requests with a structured digital form. This template captures all the information DME suppliers and healthcare providers need — patient demographics, prescribing physician contact, equipment type, medical necessity, and insurance pre-authorization status — reducing phone tag and processing delays.

Use this template

Last updated 21 August 2026

Fields in this template

Patient Full Namerequired
Date of Birthrequired
Email Addressrequired
Phone Numberrequired
Prescribing Physician Namerequired
Physician Phone Numberrequired
Equipment Type Requestedrequired
Wheelchair (manual or power) · Walker or Rollator · Crutches · Hospital Bed · CPAP / BiPAP Machine · Oxygen Equipment · Knee Scooter · Compression Garments · Other (describe below)
Medical Necessity Descriptionrequired
Rental or Purchase?required
Rental · Purchase · No Preference / Unsure
Date Equipment is Needed By
Has insurance pre-authorization been obtained?required
Yes — Authorization Obtained · No — Pending Authorization · No Insurance
Insurance Carrier Name

Who uses this template

DME suppliers and distributorsHospital discharge plannersHome health agenciesPhysical therapy clinicsOrthopedic practicesRespiratory therapy providers

About this template

A medical equipment request form standardizes how patients, caregivers, and healthcare providers request durable medical equipment (DME). Without a structured intake process, requests arrive via phone, fax, or informal notes — making it difficult to track status, verify insurance, or confirm that a valid prescription exists before fulfillment.

The most critical elements in a DME request are physician authorization, medical necessity documentation, and insurance pre-authorization status. Insurers — including Medicare and Medicaid — require clear documentation that the equipment is medically necessary for the patient's specific diagnosis. Collecting this information upfront, rather than chasing it down after submission, dramatically accelerates the approval and delivery process.

formformform makes it easy to deploy a DME request form that patients or their care teams can complete online. Submissions arrive in your inbox immediately with all the required information, and the form can be embedded on a hospital discharge planning portal, a home health agency website, or a physician practice patient portal.

12 form ideas you can build with this template

Wheelchair Request Form

Gathers mobility assessment details, body measurements, and physician prescription for manual or power wheelchair provision.

CPAP Machine Request Form

Collects sleep study results, AHI score, and physician order details for CPAP or BiPAP equipment fulfillment.

Home Oxygen Request Form

Captures oxygen saturation test results, prescribed flow rate, and delivery preferences for home oxygen equipment setup.

Hospital Bed Rental Request

Gathers home dimensions, caregiver support details, and medical diagnosis for hospital-grade bed rental after discharge.

Orthotic and Prosthetic Device Request

Collects amputation or injury details, functional goals, and prosthetist referral for custom orthotic or prosthetic device fabrication.

Post-Surgical DME Request

Processes equipment requests immediately following orthopedic surgery, capturing procedure type and anticipated recovery timeline.

Pediatric Equipment Request Form

Collects child age, weight, diagnosis, and school accommodation needs for pediatric DME items like adaptive strollers or seating systems.

Compression Garment Prescription Form

Gathers limb measurements, diagnosis (lymphedema, chronic venous insufficiency), and compression class prescription.

Ambulatory Aid Request (Walkers, Crutches)

Captures injury type, weight-bearing status, and height for proper walker or crutch selection and fitting.

Nebulizer and Respiratory Equipment Request

Collects pulmonary diagnosis, medication prescribed, and insurance details for home nebulizer or respiratory equipment provision.

Power Scooter Mobility Assessment Request

Documents ambulation distance limitation, home layout, and outdoor usage needs for power scooter eligibility assessment.

Long-Term Care Facility Equipment Request

Processes DME requests for nursing home or assisted living residents with facility name and resident room number fields.

What's included

Equipment type dropdown covering common DME categories

Prescribing physician name and phone fields

Medical necessity description for documentation

Rental vs. purchase preference question

Insurance pre-authorization status field

Needed-by date for urgency assessment

Insurance carrier field for billing lookup

Instant email notification on each submission

How to create a medical equipment request form

1
Click 'Use this template' to open the medical equipment request form in the formformform editor.
2
Customize the equipment type dropdown to reflect your specific inventory or service offerings.
3
Add a field for diagnosis code (ICD-10) if your team processes insurance billing in-house.
4
Set up email notifications so your equipment coordinator receives new requests instantly.
5
Embed the form on your DME supplier website, patient portal, or hospital discharge planning page.
6
Route completed submissions to the appropriate team member based on equipment type or insurance coverage.

Best practices for your medical equipment request form

Include a free-text 'medical necessity' field

insurance payers require narrative documentation, not just a diagnosis code, to approve durable medical equipment.

Capture the prescribing physician's phone number

you'll almost certainly need to call for signature, clarification, or a detailed written order.

Ask about pre-authorization status upfront

it immediately tells you whether you can proceed or need to wait before fulfillment.

Use a 'needed by' date field

it allows your team to triage urgent hospital discharge cases from routine requests.

Offer both rental and purchase options

some patients or payers prefer rental for short-term recovery, while others need a permanent solution.

Keep the insurance section simple at intake

carrier name and pre-auth status is enough to start; billing staff can follow up for member IDs and group numbers.

Frequently asked questions

Can patients upload a physician prescription through this form?

Patients or caregivers can attach a photo or scan of the prescription directly — add an Upload field in the editor and it arrives with the request, with a 2 MB ceiling per file that covers a typical single-page order. Because prescription details are sensitive, turn encryption on before the form goes live — it's a one-time, per-form choice that locks once the first response arrives. From then on, every file is encrypted right in the patient's browser, so your server only ever sees ciphertext, and even the filename lives inside the encrypted payload rather than sitting in your database. One caveat worth posting on the form itself: encryption inflates a file by about a third, so plan for originals closer to 1.4 MB than the full 2 MB. For a longer multi-page record or a signed Detailed Written Order that won't fit, faxing or emailing it separately still works well.

How do I add a diagnosis code field?

Open the form editor, add a short_text field labeled 'Diagnosis Code (ICD-10)' and position it in the medical necessity section. This helps your billing team before they contact the insurer.

Can I use this form for hospital discharge planning?

Yes. You can embed this form on a hospital or health system's discharge planning page, or provide the link to discharge planners who can complete it on behalf of the patient.

Is this form suitable for Medicare DME requests?

This form collects the information typically needed for Medicare DME requests — physician info, equipment type, and medical necessity. However, Medicare also requires a Detailed Written Order signed by the physician; use this form as the intake step before collecting that documentation.

How quickly will I receive a completed form?

You receive an email notification with the full submission the moment the patient or caregiver clicks submit — no delays, no batching.