Order form here - Towson Medical Equipment 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Submitted By' section with your name. This identifies who is completing the form.
3. Enter the patient's information, including their name, date of birth, address, phone number, and social security number. Ensure accuracy for proper processing.
4. Specify the start date for the equipment request and provide details about the current illness or injury, including the date of first symptoms or accident.
5. Fill in the ICD-10 diagnosis code(s) and any underlying conditions that are relevant to the patient's situation.
6. Outline the prognosis and treatment plan clearly to assist in understanding medical necessity.
7. Indicate the length of need for equipment using months (0-99), where 99 signifies a lifetime requirement.
8. List each item needed by entering quantity, HCPCS code, description of services, charge, and allowance in the provided table.
9. Finally, have the physician complete their section by providing their name, address, contact information, UPIN#, Medical Assistance Provider #, signature, and date to certify medical necessity.

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