Basic Durable Medical Equipment Request Form
Maryland Durable Medical Equipment Re-Use
Complete and submit the form below to request:
- Cane, crutches, and walkers
- Shower chairs and tub transfer benches
- Bedside commodes and toilet safety rails
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Complete the form
Review the steps - read carefully
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
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What Happens After Submission
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.