PMSI | DME Instant Referral

To quickly and easily make a durable medical equipment referral, simply complete the form below. For more information or to speak to a representative, please call 877.ASK.PMSI (877.275.7674).
All fields marked with an asterisk ( *) are mandatory
Carrier/Payor
Adjuster Name *
Adjuster Phone *
Adjuster Fax
Adjuster Email *
State of Jurisdiction *
Claim Number *  
Employer/Location
Referral Contact
Referral Phone
Referral Fax
Claimant Information
Claimant Name *
Date of Birth *
mm/dd/yyyy
Social Security Number
xxx-xx-xxxx
Height
Weight
Date of Injury *
mm/dd/yyyy
Diagnosis 1
Diagnosis 2
Phone *
Address
City
State
Zip Code
Doctor Information
Dr. Name
Dr. Address 1
Dr. Address 2
Dr. City
Dr. State
Dr. Zip
Dr. Phone
Products & Services Authorized
Product Description/HCPC Code
 Medications
 TENS Unit
 DME |  Rent    Purchase
 TENS Supplies
 Medical Supplies
 Hearing Aids/Supplies
 Orthotics/Prosthetics
 Transportation
 Home Modifications
 Vehicle Modifications
 Diagnostic Imaging
 Catostrophic
 Physical Therapy
 Nursing and Home Health
 IV Therapy
 Respiratory Therapy
 Other
 Other
 Other
Special Instructions or Handling

 I authorize you to provide items appropriate for the type of injury.
 Please contact me for final authorization before shipping.
Billing & Shipping
Payment Method:  Worker's Compensation
 Auto Personal Injury Protection (PIP)
Billing Address
City
State
Zip
Ship to Address
City
State
Zip
Ship to Phone
Date Needed
Authorized By
Title
Authorized Date
mm/dd/yyyy


If you have any questions, please call 1.877.ASK.PMSI (1.877.275.7674)