Applications and Forms

Access most commonly used forms and applications.

Code Verification

Read instructions, complete, and review the checklist within each application to ensure corresponding documentation/applicable product sample is included with submission.

Effective July 1, 2019, PDAC will only accept the applications listed below.

View the Code Verification Request Application Instructions webpage for application instructions.

• Application for Code Verification Review Form
• Reconsideration Form
• Additional Verification Information Form

• Section C/Product Specific
  • DME Supplies
  • Enteral Nutrition
  • Manual Wheelchairs
  • Orthosis
  • Section C Power Wheelchairs and Power Operated Vehicles
  • Support Surfaces
  • Surgical Dressings 
  • Therapeutic Inserts
  • Wheelchair Cushions (Backs and Seats)

DMECS

• Manufacturer Name Change (PDF, 13 KB)  - Attestation regarding Manufacturer name change resulting from a corporate merger/purchase
• Model Number Addition (PDF, 13 KB)  - Attestation regarding addition of model numbers. Must print/submit on company letterhead. Submit product literature and effective begin date for new product(s)
• Private Label Agreement – Distributor Attestation (PDF, 16 KB) - Attestation Regarding Addition of New Manufacturer/Distributor Name Resulting from Private Label Agreement – Distributor Attestation
• Private Label Agreement – Manufacturer Attestation (PDF, 16 KB) - Attestation Regarding Addition of New Manufacturer/Distributor Name Resulting from Private Label Agreement – Manufacturer Attestation

Contact

• DME PDAC Contact - Submit an email to PDAC for answers to coding and product inquiries