Healthcare Product Shipment Request

HEALTHCARE PRODUCT SHIPMENT REQUEST

Requestor / Ordering Facility

Facility Name:

Patient Information

Patient Name:

Date of Birth:    Gender:

Shipping & Billing

Ship To (if different):

Billing Party:    Account Number:

Standard Ground   Expedited/Next-Day   Requires Refrigeration   Hazardous Material Handling

Product Details (Itemized)

Provide each product line with clinical justification, quantity, and any model/lot/serial identifiers. Attach additional pages if necessary.

Clinical Justification & Medical Necessity

Provide concise clinical rationale demonstrating medical necessity for each requested product. Include diagnosis codes, expected duration of use, and alternative therapies considered.

Insurance, Prior Authorization & Coverage

Insurance Provider:    Policy/ID #:

Subscriber Name:

Prior Authorization Obtained: Yes    If yes, Prior Auth Number:

Clinical / Medical History (Relevant)

Terms, Warranties, and Shipping Acknowledgment

By submitting this request, the Requestor and Patient certify that the information provided is true and complete to the best of their knowledge. The Requestor affirms that the requested products are medically necessary and that any controlled substances or regulated items will be requested only in compliance with applicable law and accompanied by required prescriptions, permits, or authorizations. The Supplier's acceptance of this request is subject to availability, verification of payer coverage, and compliance with all applicable regulations.

Liability for loss or damage in transit is governed by the Supplier's standard shipping terms; special handling requests (e.g., refrigeration, hazardous materials) may require additional fees and documentation. The Requestor agrees to indemnify the Supplier for claims arising from inaccurate clinical information or improper handling instructions provided herein.

Privacy & Authorization to Release Protected Health Information

I authorize the release of the patient health information necessary to process this shipment, including diagnoses, treatment information, insurance information, and prior authorization documentation. This information may be disclosed to the Supplier, shipping carriers, and billing agents for the sole purpose of fulfilling this request and obtaining payment or authorization. This authorization is voluntary and may be revoked in writing, except to the extent that action has already been taken in reliance on it.

Authorization Expiration Date:

I acknowledge receipt of this request and understand that completion of shipment is subject to clinical review and payer authorization. I understand that if additional information is required, the Supplier or its agents will contact the Requestor listed above.

I have read and acknowledge the privacy authorization above and consent to the disclosure of the minimum necessary protected health information for processing this shipment.

Certification by Requestor / Prescriber

Prescriber / Authorized Clinician Name:

License Number / NPI:    Phone:

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