How to Use These Forms
Submit a referral via fax to (207) 784-7992. Simply open the form by clicking on it, complete all fields, then print for the physician’s signature prior to faxing it to Bedard Pharmacy & Medical Supplies. The forms may also be downloaded and saved for future use. Bedard will confirm receipt of your order.
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Ambulatory & Other Aides
- Canes and Crutches Requirements
- Commode Requirements
- General DME Order Form
- Patient Lift Requirements
- Seat Lift Mechanism Requirements (for Lift Chairs)
- Walker Requirements
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Breast Pumps
- Breast Pump Order Form
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Compression Therapy
- Compression Therapy Order Form
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CPAP & BiPAP
- Positive Airway Pressure (PAP) Device Requirements
- Respiratory Assist Device Order Form
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Diabetic Supplies
- Dexcom Order Form
- Diabetic Testing Supplies Order Form
- Freestyle Libre Order Form
- MaineCare CGM Policy
- Medtronic Order Form
- Omnipod Order Form
- Tandem Order Form
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DME Detailed Written Order
- DME Face to Face Rule Quick Reference Fact Sheet
- General DME Order Form
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Hospital Beds & Manual Wheelchairs
- Alternating Pressure Pad and Pump Requirements
- General DME Order Form
- Hospital Bed Requirements
- Hospital Bed Support Mattress Requirements
- Low Air Loss Mattress Requirements
- Wheelchair Requirements
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Incontinence
- Incontinence Supplies Order Form
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Negative Pressure Wound Therapy
- NPWT Order Form
- NPWT Requirements
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Respiratory
- General DME Order Form
- Nebulizer Requirements
- Icon Key:
- Word
- Excel
- PowerPoint
Advance Beneficiary Notice of Non-Coverage (ABN)
People with original Medicare whose supplier thinks that Medicare probably won’t pay for items or services can give a written notice called an “Advance Beneficiary Notice of Non-Coverage” (ABN). This form lists items that Medicare isn’t expected to pay for, an estimate of the costs and the reasons why Medicare may not pay. The purpose of the ABN is to give the beneficiary the ability to make informed decisions on whether or not to obtain the products and understand that the beneficiary may be held financially responsible for the product.
There are three options when filling out an ABN. One must be chosen:
- A beneficiary wants the items or services that may not be paid for by Medicare. The provider or supplier may ask the beneficiary to pay for them now, but also want them to submit a claim to Medicare for the items or services. If Medicare denies payment, the beneficiary is responsible for paying, but since a claim was submitted they can appeal to Medicare.
- A beneficiary wants the items or services that may not be paid for by Medicare, but does not want the provider or supplier to bill Medicare. The beneficiary may be asked to pay for the items or services now, but because they requested the provider or supplier not submit a claim to Medicare, they cannot file an appeal.
- The beneficiary does not want the items or services that may not be paid for by Medicare and they are not responsible for any payments. A claim isn’t submitted to Medicare and the beneficiary cannot file an appeal.
An ABN is not an official denial and may be appealed if payment is denied when a claim is submitted.