General Information Choose a Supplier Summary Equipment Request Documents

General Information * indicates required fields

Your Information (Healthcare Provider)

* First Name * Phone () - * Company
* Last Name

Patient Information

* First Name * DOB / / * Weight lbs.
* Last Name Gender

* Height ft in
* Phone () - * Zip Code Street Address
* Have you informed the patient that we will be contacting them regarding this equipment request?

Under new Medicare Supplier Standards, you must inform the patient that we will be contacting them prior to service or delivery of equipment.

Diagnoses (Add up to 4 codes)

Diagnoses * Code 1 Code 2 Code 3 Code 4

Primary Insurance Information

* Company * ID

Secondary Insurance Information

Company ID

Ordering Provider

* First Name * Phone () -
* Last Name
Note: Please ensure this information is charted in doctor notes.

* Product Categories

Medicare Bid Items

Non-Bid Items

Disclaimer: This website and the MED Suppliers Network are privately owned entities and are not connected with or authorized, approved or endorsed by the Social Security Administration, Department of Health & Human Services, or the Centers for Medicare and Medicaid Services. This website promotes and advertises the services of the MED Suppliers Network and its members, which are private entities. For information on the Medicare program, please visit, the official U.S. Government website for Medicare.

References in this advertisement to any device, product, service, process, or other information, by trade name, trademark, manufacturer, supplier, or otherwise do not constitute or imply endorsement, sponsorship or recommendation by The MED Group. The MED Group makes no representations as to the quality, effectiveness, suitability or appropriateness of any such device, product, service, process or other information. The user assumes all responsibility for the use of any device, product, service, process or other information mentioned herein. Under no circumstances, including negligence, shall The MED Group be liable for any direct, indirect, incidental, special or consequential damages, or lost profits, that result from the use (or inability to use) any such device, product, service, process or other information.