Standard Written Order (DMEPOS)

STANDARD WRITTEN ORDER (SWO) — DMEPOS

Order Status: [Draft / Pending Signature / Signed]

Order ID: [Internal order identifier]

Order Date: [Date order created]

Payer: [Medicare FFS / Medicare Advantage / Medicaid / Commercial] (Omit line if unknown.)

Supplier: [Supplier name; fax/contact info] (Omit line if not specified.)

Beneficiary / Patient

[INCOMPLETE: Patient identifier required before signature] (Include this line only if both Patient Name and MBI are missing.)

Patient Name: [Full legal name]

MBI: [Medicare Beneficiary Identifier] (If unknown, enter "Not provided".)

Date of Birth: [Date of birth]

Delivery Address: [Delivery address] (Omit line if same as home address.)

Treating Practitioner

Practitioner Name: [Full name]

NPI: [10-digit NPI]

Credentials: [MD / DO / PA / NP / CNS / Other]

Practice Address: [Street, City, State, ZIP]

Phone/Fax: [Phone and/or fax] (Omit line if unavailable.)

Items Ordered

(Each separately billed item, option, or accessory requires its own row. For durable items without explicit quantity, default to "1" if clinically appropriate. For recurring supplies, specify quantity with dispensing period, e.g., "120 per month".)

Item #	Description	HCPCS	Quantity	Units	Notes
[1]	[Item description: narrative, HCPCS narrative, or brand/model]	[HCPCS code] (Leave blank if not specified.)	[Quantity]	[each / set / pair / per month / other]	[Size, laterality, settings, accessories, or other dispensing details]

(Add additional rows as needed.)

[INCOMPLETE: Item description required before signature] (Include this line only if no items are identifiable from the source.)

Conditional Requirements

(Include this section only if one or more conditions apply; omit section entirely if none apply.)

WOPD Required: [Yes / No] (If Yes, add: "Signed order must be received by supplier before delivery.")

Face-to-Face Encounter: [Required / Not Required] (If Required, add: Encounter Date: [Date]; Documented in: [Note title and date].)

Prior Authorization: [Required / Not Required] (If Required, add: PA Number: [PA#]; Status: [Submitted / Approved / Pending / Denied].)

Additional Details

(Include only when clinically relevant or necessary for dispensing; omit section entirely if not applicable. Do not include coverage criteria or medical necessity narratives.)

• Diagnosis/ICD-10: [Diagnosis and ICD-10 code] (Include only if documented.)
• Duration of Need: [Length of need or "lifetime"]
• Refill Instructions: [Refill quantity/period; end date or number of refills] (For recurring supplies only.)
• Substitution: [Substitution permitted / Dispense as written]
• Other Instructions: [Clinically necessary dispensing instructions]

Signature

Treating Practitioner Signature: ____________________________

Printed Name: [Printed name]

Date Signed: [Date signed]

(The treating practitioner's signature authenticates the order content. For electronic signatures, date/time will be system-generated.)