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Request Durable Medical Equipment

Complete the form below and our team will follow up within 1 business hour to verify your insurance and schedule delivery.

We Accept:AHCCCS / MedicaidBlue Cross Blue ShieldAetnaUnited HealthcareCignaMedicare+ Many More

Equipment Request Form

For urgent requests or hospital discharges, call +1 (602) 806-6152 directly.

Patient Information

Patient Full Name *

Date of Birth

Phone Number *

Email Address

Insurance Information

Insurance Plan

Member / Policy ID

Equipment Needed

Equipment Description *

Primary Diagnosis / ICD-10

Urgency

Prescription Upload (recommended)

Upload Prescription / Doctor's Order

No file chosen

Accepted: PDF, JPG, PNG, DOC, DOCX — max 5MB. Uploading a prescription speeds up processing.

Referring Physician (optional)

Physician Name

Physician Phone

Physician NPI

Additional Notes

We'll contact you within 1 business hour. Urgent: +1 (602) 806-6152

What Happens Next

📞

We call you within 1 hour

Our team will confirm your request and gather any missing details.

✅

Insurance verification

We contact your insurance carrier and verify your benefits at no cost to you.

📋

Prior authorization

If required, we handle the prior authorization process with your physician.

🚚

Delivery scheduled

Once authorized, we schedule delivery — most within 24–48 hours.

We Accept

AHCCCS / Medicaid Blue Cross Blue Shield Aetna United Healthcare Cigna Medicare Part B Most Private Plans

Prefer to call?

📞 +1 (602) 806-6152

Mon–Fri 9 AM – 5 PM

Request Durable Medical Equipment

Equipment Request Form

🎉 Request Received!

What Happens Next

We Accept