HOME OXYGEN INFORMATION
DME AND PROSTHETICS INFORMATION
DURABLE MEDICAL EQUIPMENT (DME) EDUCATION AND TRAINING
MEDICAL JUSTIFICATION FOR THE DME
THERAPEUTIC FOOTWEAR ASSESSMENT INFORMATION
DURABLE MEDICAL EQUIPMENT (DME) AND PROSTHETICS
NOTE: Failure to thoroughly complete the RFS for DME will result in delayed patient care and prevent the VA from DME fulfillment.
***REQUIRED INFORMATION FOR ALL DME AND PROSTHETIC REQUESTS
Please see https://www.va.gov.gov/COMMUNITYCARE/providers/Service_Requirements.asp
for URGENT DME requests.
*HCPCS FOR THE ITEM(S) BEING PRESCRIBED: *BRAND, MAKE, MODEL, PART NUMBERS:
*QUANTITY:
*PROVISIONAL DIAGNOSIS:
*ICD 10:
*MEASUREMENTS:
*DELIVERY AND/OR PICKUP OPTIONS:
DELIVER TO ORDERING PROVIDERS ADDRESS
DELIVER TO VETERANS HOME
VETERAN WILL PICK UP AT THE VA MEDICAL CENTER
DELIVER TO COMMUNITY VENDOR FOR DELIVERY AND SET UP OF DME
EDUCATION, TRAINING, AND/OR FITTING:
WAS COMPLETED WAS NOT COMPLETED
*Education, training, and/or fitting of DME must be completed before DME is issued or
mailed to Veteran. If not completed, DME will be mailed to requesting provider's address.
Prescription for therapeutic footwear for severe or gross foot deformity
which cannot be accommodated with conventional footwear.
Fill out the applicable information below:
Prescription for prefabricated therapeutic footwear due to disease
pathology resulting in neuropathy or peripheral artery disease.
Check appropriate diabetic/amputation risk score below:
LEFT FOOT RIGHT FOOT BILATERAL
PREFABRICATED THERAPEUTIC FOOTWEAR
CUSTOM THERAPEUTIC FOOTWEAR
DESCRIBE FOOT DEFORMITY:
Risk Score 2: patient demonstrated sensory loss (inability to
perceive the Semmes-Weinstein 5.07 monofilament), diminished
circulation as evidenced by absent or weakly palpable pulses, foot
deformity, or minor foot infection, and a diagnosis of diabetes.
Risk Score 3: patient demonstrated peripheral neuropathy with
sensory loss (i.e., inability to perceive the Semmes-Weinstein 5.07
monofilament), and diminished circulation, and foot deformity, or
minor foot infection and a diagnosis of diabetes, or any of the
following by itself: (1) Prior ulcer, osteomyelitis or history of prior
amputation; (2) Severe Peripheral Vascular Disease (PVD)
(intermittent claudication, dependent rubor with pallor on elevation,
or critical limb ischemia manifested by rest pain, ulceration or
gangrene); (3) Charcot's joint disease with foot deformity; and (4)
End Stage Renal Disease.
NOTE: Only patients who are experiencing medical conditions noted
in the risk scores can be prescribed therapeutic/diabetic footwear.
I do hereby attest that the forgoing information is true, accurate, and complete to the best of my knowledge and I understand that any falsification, omission, or
concealment of material fact may subject me to administrative, civil, or criminal liability.
I do hereby acknowledge that VA reserves the right to perform the requested service(s) if the following criteria are met: (1) The patient agrees to receive services from
VA (2) Service(s) are available at VA facility and are able to be provided by the clinically indicated date (3) It is determined to be within the patients best interest.
Upon completion of the requested service(s), VA will provide all resulting medical documentation to the ordering provider. If all criteria listed are not true and VA
agrees the service(s) are clinically indicated, VA will provide a referral for services to be performed in the community.
I do hereby attest that upon receipt of order/consult results, I will assume responsibility for reviewing said results, addressing significant findings, and providing
continued care.
*DATE
(mm/dd/yyyy):
*PROVIDER SIGNATURE:
VA FORM 10-10172, MAY 2021
PAGE 2
*ATTESTATION:
PA02 AT REST: 02SAT AT REST: OXYGEN FLOW RATE:
EXTENT OF SUPPORT (Continuous,
Intermittent, Specific Activity):
OXYGEN EQUIPMENT (Stationary/Portable): DELIVERY SYSTEM (Cannula, Mask, Other):
REQUESTING PROVIDER'S ADDRESS:
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