Document Library

Use this form to submit a Patient Referral for Complex Rehab Technology (CRT) equipment, Durable Medical Equipment (DME), and/or Repair orders.

Prescription/Rx form for all CRT, DME, and Repair Orders

Return & Exchange Policy, Warranty Policy, Complaint Policy, Storage & Disposal, Rental Agreement, HIPAA Privacy Notice, Patient Rights & Responsibilities, 30 Supplier Standards Notice, etc.

Use this form to file a State Fair Hearing (appeal) for Services Denied by Medi-Cal

For a Motorized Wheelchair, Custom or Standard

For Manual Wheelchair, Standard or Custom

For DME Except Wheelchairs & Scooters

For Power Operated Vehicles AKA Scooter, Standard or Bariatric

Manual Wheelchair

Group I & II Support Surface Mattress

Quarterly Report