The following forms are the most commonly used forms to request durable medical and respiratory equipment and supplies. If you do not see the form you are looking for or have any questions, please contact provider services at: 1-888-865-5290.
Funds’ Medical Justification Form for:
Durable Medical and Respiratory Equipment
CMS Forms and Instructions:
CMS 846 – Pneumatic Compression Devices
CMS 847 – Osteogenesis Stimulators
CMS 849 – Seat Lift Mechanisms
CMS 10125 – External Infusion Pumps
CMS 10126 – Enteral and Parenteral Nutrition
CMS 854 – Continuation Form (for any of the above CMS forms)
