272 EQ DME Non Wheelchair - KEPRO / NHMedicaid Home 2026

1. Click ‘Get Form’ to open the 272 EQ DME Non Wheelchair form in the editor.
2. Begin by entering the recipient's name and Medicaid ID number in the designated fields. Ensure all information is printed clearly.
3. Fill in the recipient's height and weight accurately, as this information is crucial for equipment recommendations.
4. Indicate whether the recipient has an alternate insurance plan by selecting 'Yes' or 'No' and provide the name of the insurance plan if applicable.
5. Complete the provider information section, including the evaluator's name, NH Medicaid provider number, address, and contact details.
6. In the diagnosis section, write a clear description of the recipient’s condition without using ICD codes.
7. Select the equipment requested from options like Stander or Gait Trainer and provide medical justification for each request.
8. Answer questions regarding current equipment status and any plans for funding from other sources. Provide detailed explanations where necessary.
9. Review all entries for accuracy before saving your work. Utilize our platform’s features to sign and share your completed form securely.

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