Verify Medicare Eligibility

Securely submit your information so our team can coordinate eligibility verification and documentation steps with your physician/clinic.

Patient

Physician & DME

Authorization

Patient Information

First Name *

Last Name *

Phone Number *

US format required.

Email Address *

Medicare Part B ID Number *

Stored securely. Only the last 4 digits are shown in summaries.

Date of Birth *

Residential Address

Street Address Line 1 *

Street Address Line 2

City *

State *

ZIP Code *

Treating Physician & Clinic

Physician Full Name *

Physician NPI Number

Optional but recommended.

Clinic Name *

Clinic Email Address *

Clinic Phone Number *

Clinic Address

Street Address Line 1 *

Street Address Line 2

City *

State *

ZIP Code *

DME Information

Type of DME Needed *

Has the doctor already prescribed DME? *

Yes No

HIPAA & Authorization

I understand that BSA DME INC. may contact my physician and/or clinic for the purpose of verifying medical necessity and Medicare eligibility for durable medical equipment. I authorize BSA DME INC. to communicate with my physician and their clinic regarding my medical equipment request and related documentation. By submitting this form, I consent to be contacted by BSA DME INC. via phone, email, or SMS regarding my Medicare eligibility and durable medical equipment request.

Compliance note: Do not submit medical records or diagnosis details. Only verification details are collected.

Submission of this form does not guarantee Medicare coverage. Coverage depends on medical necessity and proper documentation.