7 Element Order

Note: Medicare requires that ALL 7 elements MUST be completed by the ordering provider and MUST be
in the same provider’s handwriting.

1.) Patient Name: ___________________________________________________________________

2.) Date of Face to Face: _______________________________________________________________

3.) ICD-10 Code Diagnosis
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________

4.) Length of Need: __________________________________________________ (99 Months = Lifetime)

5.) Equipment Ordered: _______________________________________________________________

_______________________________________________________________________________

6.) Provider’s Signature: _______________________________________________(No Signature Stamps)

Provider’s Name Printed: ____________________________________________________________

7.) Date of Provider’s Signature: _________________________________________________________

Provider NPI: ____________________________________________________________________

This order must be received within 45 days of the face-to-face exam.

Per cms.gov: The supplier may provide a template order listing the seven required elements but is prohibited from completing any part of
it. The treating practitioner completing the face-to-face requirements must write the 7-Element Order. The 7-Element Order may only be
written after the completion of the face-to-face exam requirements. Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND
PAYMENT RULES section for information regarding the statutory requirements for PMDs.
(Rev. 1/5/17)