MassHealth DME providers use this form to obtain a prescription and letter of medical necessity from the ordering practitioner, and attach it to prior authorization requests for durable medical equipment and medical supplies. The practitioner lists items with HCPCS codes, length of need or monthly quantity and refills, and writes the medical justification, including settings, therapeutic outcomes and previous treatment plans.
The DME provider completes Sections 1 to 5 and 8. The ordering practitioner or their employee completes Sections 4A, 4B, 5A and 6, and the practitioner (MD, DO, NP, clinical nurse specialist or PA) personally signs Section 7.
Download the current version from the source each time; forms change without notice.
MassHealth General Prescription and Medical Necessity Review Form for Durable Medical Equipment and Medical Supplies
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. Wet signatures and electronic signatures as defined in Durable Medical Equipment Bulletin 31 are both acceptable. Signature stamps, date stamps and the signature of anyone other than the ordering practitioner are not. For a wet signature, the practitioner also prints their legal name and checks their credential.
Sections 4A and 4B (length of need for equipment), 5A (monthly quantity and refills for supplies) and 6 (medical justification with any settings, outcomes and prior treatment) may be completed by the practitioner or their employee. Section 7, the attestation under 130 CMR 450.204, must be signed by the practitioner named in Section 2.
When MassHealth has a Medical Necessity Review Form for the specific item. Absorbent products, hospital beds, enteral nutrition, support surfaces, gait trainers and ambulatory infusion devices such as insulin pumps have their own forms, and personal emergency response systems use the PERS General Prescription Form.