Durable Medical Equipment Request Form Details
Durable Medical Equipment Request Form
Maryland Durable Medical Equipment Re-Use
Complete and submit the form below to request:
- Canes, crutches, and walkers
- Rollators
- Shower chairs and tub transfer benches
- Bedside commodes and toilet safety rails
- Bedrails and transfer boards
The following items may be requested. Requestors seeking any of the items below must provide a Complex Request Form (Parts B and C) completed by a healthcare provider.
- Manual wheelchairs
- Transport wheelchairs
- Knee Scooters
- Semi/Electric Home Hospital Beds
- Patient (Hoyer) Lift
- Trapeze Bars
- Overbed Tables
- Power wheelchairs (Physical or Occupational Therapist only)
- Power Scooter (Physical or Occupational Therapist only)
Click the Blue “Apply Online” button below to begin your request.
Apply or Register
Ready to apply?
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Apply OnlineOnline Application
Complete the form
Instructions
Review the steps - read carefully
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Click "Apply Online" above to begin completing a request form. Once complete, click "Submit" at the bottom of the form. Note that all fields denoted with an “*” are required. Failure to provide this information will void your request
What Happens After Submission
Read carefully
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After a form is submitted, the form will be "In-Review". Once reviewed, we will contact you via the preferred method of contact provided to inform you if the requested equipment is in-stock and to schedule a pickup appointment.
Agency/Contact
Who issues the Form?
Contact Information
Email: dme.mdoa@maryland.gov
Address