Provider Resources

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Order Checklists

Required documents and information for each equipment category — keeps orders moving same-day.

Respiratory

Oxygen Therapy

Demographics, F2F notes, Group I/II/III qualifying tests, SWO.

PDF

PAP (CPAP / BiLevel)

Sleep study, titration, F2F notes, CPAP/BiLevel SWO.

PDF

Respiratory Assist Device (RAD)

For BiLevel with backup rate (E0470 / E0471). Qualifying condition + ABG.

PDF

Ventilator

Trilogy 100, LTV series, VC+ Pro. Chronic respiratory failure docs, backup plan.

PDF

Nebulizer & Compressor

Obstructive pulmonary disease docs, inhaled meds & supplies SWO.

PDF

Cough Assist

Philips CoughAssist T70. Neuromuscular disease docs, PCF measurement.

PDF

Suction Pump / Aspirator

Inability to clear secretions, caregiver training, supplies.

PDF

High-Flow Therapy (Airvo)

Heated humidified high-flow. Failure of standard oxygen, settings.

PDF

Tracheostomy Supplies

Trach tube brand/size (Shiley), suction catheters, monthly supply list.

PDF

Mobility

Manual Wheelchair

Mobility evaluation, MRADL inability, sizing, bariatric notes.

PDF

Transport Chair

Caregiver-propelled (E1037 / E1038). Why a self-propelled wheelchair isn't appropriate.

PDF

Walker / Rollator

Standard, 2-wheel, 4-wheel rollators. Mobility limitation docs.

PDF

Cane / Crutches

Standard, quad, offset canes; axillary / forearm crutches.

PDF

Beds & Support Surfaces

Hospital Bed & Accessories

Manual / semi-electric / full-electric / bariatric. Positioning, traction needs.

PDF

Low-Air-Loss (LAL) Mattress

Group 2 support surface. Stage III/IV pressure injuries or recent flap/graft.

PDF

Geri Chair

Reclining/geriatric chair. Positioning needs, ABN if non-covered.

PDF

Patient Lifts, Bathroom & Nutrition

Patient Lift

Hoyer hydraulic / electric. Sling type, weight capacity.

PDF

Commode

Standard, drop-arm, bariatric, bedside, 3-in-1. Inability to use regular toilet.

PDF

Enteral Nutrition

Kangaroo Joey pump, NG/NJ/G/J tubes, bags, formula. Permanent feeding need.

PDF

How to Submit Orders

Fax orders to: (718) 369-5858

Email orders to: info@domehc.com

Or call us: (718) 854-5501 to speak with our intake team.

Once we receive the completed checklist and supporting documents, we will submit your order for processing.

Need a checklist not listed?

Contact our provider relations team and we'll send you the specific order requirements.

Contact Provider Team   Call (718) 854-5501