Back to Providers

Medicare Prescription Forms

Please note: Forms are valid only for Washington State.

Bed Hospital Semi-Electric
BedHospitalSemi-Electric_Rx.pdf
Adobe Acrobat document [10.0 KB]

Cane
Cane_Rx.pdf
Adobe Acrobat document [26.3 KB]

Cane Quad
CaneQuad_Rx.pdf
Adobe Acrobat document [31.3 KB]

Commode
Commode_Rx.pdf
Adobe Acrobat document [7.3 KB]

Commode Drop Arm
CommodeDropArm_Rx.pdf
Adobe Acrobat document [7.5 KB]

Cushions Info
Cushions_Info-Rx.pdf
Adobe Acrobat document [212.2 KB]

Diabetic Supply
Diabetic_Rx.pdf
Adobe Acrobat document [156.4 KB]

Equipment Misc
Equipment_Rx_Miscellaneous.pdf
Adobe Acrobat document [7.1 KB]

Fax Cover Sheet Misc
Fax_Cover_Sheet_Miscellaneous.pdf
Adobe Acrobat document [147.9 KB]

Knee Immobilizer
Knee_Immobilizer_without_Joints_Rx.pdf
Adobe Acrobat document [83.9 KB]

Lumbar Support
Lumbar_Support_RX.pdf
Adobe Acrobat document [7.7 KB]

Mattress Low Air Loss
Mattress_Low_Air_Loss_Rx.pdf
Adobe Acrobat document [146.4 KB]

Mobility Misc
Mobility Rx Miscellaneous.doc
Microsoft Word document [45.5 KB]

Nebulizer
Nebulizer_RX.pdf
Adobe Acrobat document [151.1 KB]

Ostomy
Ostomy_Rx.pdf
Adobe Acrobat document [143.5 KB]

Patient Lift
Patient_Lift_Rx.pdf
Adobe Acrobat document [6.7 KB]

Pressure Pad Alternating with Pump
Pressure_Pad_Alternating_with_Pump_RX.pd[...]
Adobe Acrobat document [66.0 KB]

Scooter Power
Scooter_Power_Rx.pdf
Adobe Acrobat document [272.9 KB]

Seat Lift Mechanism
SeatLiftMechanism_Rx-FaxCoverSheet.pdf
Adobe Acrobat document [211.8 KB]

Stockings
Stockings_Rx.pdf
Adobe Acrobat document [7.0 KB]

Suction Pump
Suction_Pump_Rx.pdf
Adobe Acrobat document [8.0 KB]

Supply Misc
Supply_Rx_Miscellaneous.pdf
Adobe Acrobat document [7.7 KB]

Surgical Dressing
Surgical_Dressing_Rx.pdf
Adobe Acrobat document [76.8 KB]

TENS Unit
TENSUnit_Rx-FaxCoverSheet.pdf
Adobe Acrobat document [1.2 MB]

Traction Device
Traction_Device_Rx.pdf
Adobe Acrobat document [8.1 KB]

Trapeze Bed Mount
Trapeze_Bed_Mount_Rx.pdf
Adobe Acrobat document [6.7 KB]

Trapeze Free Standing
Trapeze_Free_Standing_Rx.pdf
Adobe Acrobat document [6.6 KB]

Urological
Urological_Rx.pdf
Adobe Acrobat document [8.7 KB]

Walker Folding
Walker Folding Rx.doc
Microsoft Word document [49.0 KB]

Walker Folding Three Wheeled
Walker Folding 3 Wheeled Rx.doc
Microsoft Word document [61.0 KB]

Walker Folding Wheeled
Walker Folding Wheeled Rx.doc
Microsoft Word document [47.0 KB]

Walker Folding Wheeled with Seat
Walker Folding Wheeled with Seat Rx.doc
Microsoft Word document [47.5 KB]

Wheelchair Heavy Duty
Wheelchair Heavy Duty Rx.doc
Microsoft Word document [49.5 KB]

Wheelchair Lightweight
Wheelchair Lightweight Rx.doc
Microsoft Word document [48.5 KB]

Wheelchair Power
Wheelchair Power Rx.doc
Microsoft Word document [53.5 KB]

Wheelchair Standard
Wheelchair Standard Rx.doc
Microsoft Word document [48.0 KB]

Wheeled Chair Transport Rollabout
WheeledChairTransportRollabout_Rx.pdf
Adobe Acrobat document [26.3 KB]

COMING SOON