Star DME Medical & Surgical Supply
141-04 Rockaway Blvd, Suite 1F, Jamaica, NY 11436
NY license #2090784 · Accredited by The Compliance Team
141-04 Rockaway Blvd, Suite 1F, Jamaica, NY 11436
NY license #2090784 · Accredited by The Compliance Team
FAX TO
(844) 438-5893
Phone (917) 300-2692
(844) 438-5893
Phone (917) 300-2692
DME referral / prescription
Patient
Name
Date of birth
Phone
Address
Insurance and member ID
Height / weight
Case type: ☐ Medicare ☐ Medicaid ☐ Commercial ☐ No-Fault (claim # and accident date below) ☐ Workers' Comp (WCB case # and injury date below)
Claim / WCB case #
Date of accident or injury
Order
☐ Back brace (L0650)☐ Knee brace (L1833)☐ Wrist hand orthosis (L3916)☐ AFO (L1933 / L1952)☐ CAM walking boot (L4361)☐ CGM: FreeStyle Libre 3 Plus☐ Diabetic shoes (A5500)☐ Inserts (A5512 / A5513)☐ Incontinence supplies☐ Other:
Side: ☐ Left ☐ Right ☐ Both Length of need: ☐ 6 months ☐ 12 months ☐ 99 (lifetime) ☐ Other ______
Diagnosis and ICD-10 code(s)
Clinical reason / notes (attach the most recent visit note)
Ordering practitioner
Name
NPI
Practice phone
Practice fax
Signature
Date
Please include: insurance card (front and back) and a recent visit note supporting the item. For diabetic shoes, also send the certifying statement from the physician managing the patient's diabetes. Questions: (917) 300-2692 · orders@stardme.com