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The form collects clinical requirements, including physician orders, notes, and recent diagnostics, and requires notification for any date-of-service change. It includes expedited request instructions, requested services selection (prosthetic vs orthotics, purchase vs rental), discharge and dispensed item status, and required fax submission lines by state.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/dme-authorization-request-form-2026/283812/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/dme-authorization-request-form-2026/283812.png","ImageObject",442,249,{"name":88,"@type":89},"Miles","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-28","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":25},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to submit a DME authorization request?","Question",{"text":108,"@type":109},"Submission requires current physician orders, notes, and recent diagnostics as supporting documentation, along with relevant diagnosis codes and requested service details.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"When are expedited requests appropriate?",{"text":113,"@type":109},"Expedited requests are for cases where standard determination time could seriously jeopardize the member’s life/health or their ability to regain maximum function; the form instructs calling the expedited request number.",{"name":115,"@type":106,"acceptedAnswer":116},"How should purchase vs. rental and prosthetics vs. orthotics be handled?",{"text":117,"@type":109},"Submit separate requests for prosthetics versus orthotics and for purchases versus rentals, and indicate whether the item is needed for discharge and whether it has already been dispensed.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283812,1790959380,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":25,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},13056703019404,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Want faster service? Use our Provider [Portal at](Portal at provider.wellcare.com)[ provider.wellcare.com](Portal at provider.wellcare.com).  \nDME Authorization Request Form  \n*Indicates a required field  \nRequirements: Clinical information and supporting documentation should consist of current physician orders, notes, and recent diagnostics. Notification is required for any date-of-service change.  \nExpedited Requests: If the standard time to make a determination could seriously jeopardize the life and/or health of the member or the member’s ability to regain maximum function, please call 1-855-538-0454.  \n Please fax completed form to appropriate number at bottom of form.  \n\n| Requestor Name* : | Fax* : | Phone* : |\n| --- | --- | --- |\n\n\n| Member Information (please print) |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Wellcare ID* : |  | Medicaid/Medicare ID: |  |  |  |  |  |\n| Last Name* : |  | First Name, MI* : |  |  | Date of Birth* :/ / |  |  |\n| Ordering Provider (please print) |  |  |  |  |  |  |  |\n| Wellcare ID: |  | NPI/Tax ID* : |  |  |  |  |  |\n| Provider Name* : |  | Fax* : |  |  | Phone: |  |  |\n| Address: |  | City: |  |  | State: |  | ZIP Code: |\n| Dispensing Provider (please print) |  |  |  |  |  |  |  |\n| Wellcare ID: |  | □ Plan to Assign |  | NPI/Tax ID* : |  |  |  |\n| Provider Name* : |  | Fax* : |  |  | Phone: |  |  |\n| Address: |  | City: |  |  | State: |  | ZIP Code: |\n| Place of Service* |  |  |  |  |  |  |  |\n| □ Office (11) □ Home (12) □ Other (please specify):   |  |  |  |  |  |  |  |\n| Diagnosis Codes* |  |  |  |  |  |  |  |\n| ICD-10: | ICD-10: |  | ICD-10: |  |  | ICD-10: |  |\n\n(continued)  \n©Wellcare 2026 5693714_NA6PCARFRME  \nInternal Approved 02032026  \n\n| Requested Services (please print) |  |  |  |\n| --- | --- | --- | --- |\n| Please submit separate request for prosthetics vs. orthotics and [purchases vs. rentals](purchases vs. rentals). |  |  |  |\n| □ Prosthetic □ Orthotics\u003Cbr>□ Other (please specify):   |  | Is item needed for discharge? □ Yes □ No\u003Cbr>Discharge Date: / / |  |\n| □ Purchase\u003Cbr>□ Rental ✕   Months |  | Has this item been dispensed?* □ Yes □ No Dispensed Date: / / |  |\n| Codes* | Description |  | Quantity |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n| HCPC Code: |  |  |  |\n\n Please fax completed form to:  \n\n| Medicare Fax Lines |  |\n| --- | --- |\n| Connecticut: 1-866-455-6529 | Kentucky: 1-888-361-5684 |\n| Florida Medicare only: 1-877-892-8216 | New Jersey: 1-877-892-8221 |\n| Georgia Medicare only: 1-877-892-8213 | New York: 1-877-892-8214 |\n| Florida/Georgia Dual: 1-877-277-1820 | Texas: 1-877-894-2034 |\n| Illinois: 1-877-899-2044 | All others: 1-888-361-5684 |\n\n[wellcare.com](wellcare.com)","cbCaiuHZ9JTTv3uF","https://ap.wps.com/l/cbCaiuHZ9JTTv3uF","pdf",105199,"English","# DME Authorization Request Form\n## Submission requirements\n## Requestor, member, and provider details\n## Requested services and coding\n## Fax lines by state","[{\"question\":\"What information is required to submit a DME authorization request?\",\"answer\":\"Submission requires current physician orders, notes, and recent diagnostics as supporting documentation, along with relevant diagnosis codes and requested service details.\"},{\"question\":\"When are expedited requests appropriate?\",\"answer\":\"Expedited requests are for cases where standard determination time could seriously jeopardize the member’s life/health or their ability to regain maximum function; the form instructs calling the expedited request number.\"},{\"question\":\"How should purchase vs. rental and prosthetics vs. orthotics be handled?\",\"answer\":\"Submit separate requests for prosthetics versus orthotics and for purchases versus rentals, and indicate whether the item is needed for discharge and whether it has already been dispensed.\"}]","DME Authorization Request Form - 2026 | PDF",1789620204]