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Provider referral

Send a DME referral.

We confirm within one business day, verify benefits, and chase any missing documentation directly with your office — not the patient.

  • One business day to first response

    Triaged the morning it lands. If we need anything from you to proceed, we'll call or fax — not email a portal link the patient has to forward.

  • We chase documentation, not patients

    If the order's missing a face sheet or AOB, we call your office. The patient gets one update from us, when the equipment is scheduled.

  • HIPAA-covered submission

    This form lives behind our HIPAA-covered AWS stack. No PHI is sent over email — internal staff log in to review every referral.

Prefer another channel?

Fax

1-855-365-3159

Fax the Rx + chart notes straight from your clinic — we confirm receipt and follow up with your office, not the patient.

Email

referrals@affinitymedservices.com

HIPAA-secure email. Attach Rx + face sheet.

Phone

1-800-779-5479

Mon–Thu 8 AM – 5 PM CT · Fri 8 AM – 12 PM CT. Ask for intake.

Prefer to fax?

Most clinics already refer DME by fax — that works perfectly for us. Fax the order and chart notes straight from your office; we confirm receipt and chase any documentation gaps with you, not the patient.

Fax: 1-855-365-3159

All referral options

Referral details

Fill in what you have on hand — we'll request the rest from your office or the patient directly. Required fields are marked with .

Prescribing physician

The clinician who wrote the order. At least one contact method is required so we can chase missing documentation.

Patient

Name is required. Everything else helps speed up triage but is optional — leave blank if you'll send a face sheet.

Insurance

Helps us verify benefits before reaching out to the patient. Optional — we'll capture this on the verification call if you skip.

Equipment & diagnosis

Tell us what you're prescribing. Equipment category lets us route to the right intake specialist immediately.

Comma or newline separated. We'll match these against the Medicare LCD for the equipment category.

Additional notes

Anything else our intake team should know — clinical context, urgency, special instructions.

You'll get a reference number on the next screen. Documentation (Rx, face sheet, etc.) can be faxed or emailed to us — instructions on the confirmation page.

Have a question?

Three fields, real payer data, plain-English answer. Or talk to a person — we're fast.

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Where we serve1-800-779-5479