PRESCRIPTION FOR DURABLE MEDICAL EQUIPMENT

Patient Name:    

Patient Address: 

Diagnosis:      

Date of Diagnosis:

Equipment:   

Length of Need:  

Physician Signature:           Date: 

Physician Medicaid Provider ID No.: 

Physician NPI: 

Physician Address: 

Physician Phone:       Physician Fax Number: 

Mail to:

Augmentative Communication Consultants, Inc.

P. O. Box 731

Moon Township, PA  15108