AuBurn Pharmacy Compliance Manual



HME Forms

Detailed Physician Order for Nebulizer_2
Detailed Physician Order for Nebulizer_1
Oxygen set up checklist
Bedside Commode Physician Order
BiPAP asv-st Physician Order
BIPAP Physician Order
BIPAP Supplies Order Form
Cane Detailed Physician Order
COSS AUTHORIZATION FORM
CPAP PHYSICIAN ORDER
CPM Physician Orders
Crutches Physician Order
DM Shoes Certifying Physician2
DM Supplies Detailed physician Order
Generic Physician Order
Gr 1 Support Surface Detailed Physician Order
Gr II Support Surface Detailed Physician Order
Hospital Bed Detailed Physician Order
Nutritional Physician Order Enteral
O2 Home Visit-1
O2 Home Visit
Ostomy Physician Order
PATIENT LIFT Physician Order
POV Detailed Physician Order2
PWC Detailed Physician Order
Suction Pump Detailed Physician Order
Trapeze Bar & other Hospital Bed Accessories Physician Order
Urological Detailed PO2
Walker Detailed Physician Order
Wheel Chair Cushion Physician Order
Wheelchair Physician Order
Oxygen Quality Assurance
CPAP/BIPAP Setup Information
CPAP Supplies Physician Order
Oxygen shipping log
Patient/Caregiver Instructional Checklist for CPAP/BiPAP
Release of Liability for Refusal of Physician Ordered Equipment & Services
Set-Up of Oxygen Respiratory
Pick-Up of Oxygen Equipment
Cross Authorization Form
Quote Form

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Insulin & CGM
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Basic Patient Packet (All Forms) 

Individual Forms 

Benefit Check
Assignment of Benefits
Proof of Medical Necessity 
Intake Forms & Delivery Instructions
Satisfaction & Follow-Up Forms


DME Billing Forms
Breast Pump Information & Forms

BCBS of KANSAS and KC Breast Pump Info

DME Inspection-Repair Form
Medela 2017 Price list
Medela Benefit Check
Auburn Medela Prescription Form

Equipment Rental / Purchase 

Basic Patient Packet (All Forms) 

Individual Forms

1. DMEPOS Supplier Standards
2. 2013 NOPP (HIPPA)
3. Equipment Warranty Information
4. Complaint Resolution Protocol
5. Complaint Log
6. Pt Rights & Responsibilities
7. DME Intake Form 2017
8. AOB Form (Assignment of Benefits) 2017
9. Medicare Rent Purchase Agreement
10 AOB Form (Assignment of Benefits) 2017
11 Check List to determine Pt Liability and Eligibility
12 DME (ALL) Benefit Check
13 DME Generic Follow-up form
14 DME Intake Form 2017
15. Patient Satisfaction Survey

Equipment Tracking Forms

DME Equipment Rental Form
DME Instruction Delivery sheet
DME Inspection-Repair Form
Equipment History Log
Medicare Rental Delivery-Pick-Up Ticket


Nebulizer and Inhalation Meds

Basic Patient Packet (All Forms) 

Individual Forms

1. DMEPOS Supplier Standards
2. 2013 NOPP (HIPPA)
3. Equipment Warranty Information
4. Complaint Resolution Protocol
5. Pt Rights & Responsibilities
6. DME Intake Form 2017
7. AOB Form (Assignment of Benefits) 2017
8. Medicare Rent Purchase Agreement
9. DME Inspection-Repair Form
10. DME Instruction Delivery sheet
11. Follow-up form for Nebulizer and meds

Glucose Testing Supplies

Basic Patient Packet (All Forms)

Individual Forms

1. DMEPOS Supplier Standards
2. 2013 NOPP (HIPPA)
3. Equipment Warranty Information
4. Complaint Resolution Protocol
5. Pt Rights & Responsibilities
6. DME Intake Form 2017
7. AOB Form (Assignment of Benefits) 2017
8. Medicare Rent Purchase Agreement
9. Medicare Diabetic Testing Guidelines
10. DME Inspection-Repair Form
11. New Diabetic follow-up form
12. Patient Satisfaction Survey

Diabetic Shoes and Inserts

Shoe Fitter Training Videos

1. Foam Impression
2. Foot Measurement
3. Heat Molding

Basic Patient Packet (All Forms) 

Individual Forms

Check List for Fitting Diabetic Shoes (First Fitting)
Diabetic Shoe Break-in Information
Diabetic Shoe Checklist- Medicare Part B 
Diabetic Shoe Fitting-Patient Information
Final Fitting of Diabetic Shoes
Medicare Proof of Delivery and Return Policy for Diabetic Shoes
Order for Diabetic Shoes and Inserts
Statement of Certifying Physician for Therapeutic Shoes

Walkers - Rollators

Basic Patient Packet (All Forms) 

Individual Forms

1. Patient Info Packet-DME
2. DMEPOS Supplier Standards
3. 2013 NOPP (HIPPA)
4. Equipment Warranty Information
5. Complaint Resolution Protocol
6. Pt Rights & Responsibilities
7. DME Intake Form 2017
8. AOB Form (Assignment of Benefits) 2017
9. Medicare Rent Purchase Agreement

Equipment History Forms

1. DME Inspection-Repair Form
2.DME (General) Instruction Delivery
3.DME (Walkers-Rollators) Instruction Delivery

4. DME (General) Follow-Up form
5.DME (Walker-Rollator) Follow-Up Form