CDI Document Center
Forms & Documentation
Download, complete, and submit the forms needed to access durable medical equipment, Medicare coverage, and CDI services — all in one place.
2
Forms available
PDF
Free download
Medicare
Compliant
Important: All forms on this page must be completed and signed by a licensed healthcare professional before submission. A completed form does not guarantee insurance coverage. For questions, contact us at info@centerfordisabilityinnovations.com or call 866-992-7702.
Available forms
New Client & Order Documents
Two documents are required to initiate a new DME order through CDI. Complete the Order Intake Form first, then have your provider sign the DME Prescription.
New Client Order Intake Form
Required for all new DME orders · Completed by CDI intake staff or referring provider · Updated 2026
Why the Order Intake Form Is Required
The Order Intake Form captures all information needed to initiate a Medicare or insurance DME order — including beneficiary details, physician credentials, prior authorization status, same/similar equipment history, and medical necessity documentation. This is the first document completed for every new client.
Without a properly completed intake form, order processing may be delayed — even when the equipment is medically necessary.
What this form covers
- Beneficiary name, date of birth, MBI, weight, height, and address
- Legally responsible representative information
- Ordering physician name, NPI, address, specialty, and PECOS enrollment
- Same or similar equipment history, rental dates, and return status
- Medicare Advantage plan enrollment and Fee-For-Service status
- SNF or home health episode discharge dates
- Repair documentation: manufacturer, model, serial number, and reason
- SWO on file, prior authorization, ABN requirement, and primary/secondary insurer
- Primary and secondary diagnoses for medical necessity
This form does not replace obtaining an Advance Beneficiary Notice (ABN) if there is reason to believe the item(s) may be denied. Please refer to the Noridian Medicare website for information about same or similar equipment, ABNs, and Limitation of Liability.
CDI DME Prescription / Script
Required for Medicare Part B and insurance coverage · Must be completed by a licensed provider
Why a DME Prescription Is Important
A Durable Medical Equipment (DME) prescription — also called a DME script — is a required document for equipment covered by Medicare and most insurance plans. It allows your healthcare provider to formally document medical necessity, ensuring you receive the right equipment and that your coverage claim is processed without delay.
Without a properly completed DME prescription, insurance coverage may be delayed or denied — even when the equipment is medically necessary.
What this form does
- Confirms that the equipment is medically necessary
- Specifies the exact type of equipment required
- Supports Medicare Part B or Medicare Advantage coverage
- Reduces delays caused by missing or incomplete documentation
- Ensures the equipment is appropriate for safe use in the home
A completed DME prescription does not guarantee insurance coverage. Coverage decisions depend on medical necessity, plan guidelines, and supplier participation. For official Medicare information, visit www.medicare.gov.
Who should use this form
Is this form for you?
You may need a DME prescription in any of the following situations.
Applying for Medicare coverage
For walkers, wheelchairs, rollators, beds, or other equipment under Part B.
Replacing or upgrading equipment
A new prescription may be required when existing equipment needs replacement.
Post-surgery recovery
After hip, knee, or other procedures requiring mobility or homecare equipment.
Managing a chronic condition
Conditions affecting mobility, balance, breathing, or daily living activities.
Oxygen or respiratory equipment
Oxygen concentrators and respiratory DME require a signed prescription.
Caregiver or provider ordering
Caregivers and facilities ordering equipment on behalf of a patient.
Step-by-step
How to use these forms
Follow these steps to ensure your documentation is completed correctly and processed without delays.
1
Download the Order Intake Form
Click the download button above to get the fillable PDF. It's free and requires no account or sign-up. Complete all beneficiary and physician fields.
2
Download the DME Prescription Form
Get the DME script PDF and bring it to your healthcare provider. Your doctor, nurse practitioner, or qualified provider must complete and sign it.
3
Submit both completed forms to CDI
Return the signed documents along with any required insurance or identification documentation to our team.
4
We process your request
Once received, our team will use the documentation to process your DME request efficiently and coordinate with your insurer.
Need help with your paperwork?
Our team can guide you through the documentation process, answer questions about Medicare coverage, and help ensure your request is processed smoothly.
© 2025 Center for Disabilities Innovations · 872 Route 376, Wappingers Falls, NY 12590 · 866-992-7702 · Forms are for informational purposes. Always confirm coverage with your insurer.
