Evaluation
AffloVest Eval
Evaluation form for AffloVest equipment requests.
Patient Equipment Evaluation & Special Request Forms
Select a secure EWMS patient form below, or use a primary EWMS form to place an order or start as a new patient.For equipment concerns, use the warranty form.
Signed proof of delivery is now required
Effective October 10, 2026, the Department of Labor’s DEEOIC program requires signed proof of delivery for durable medical equipment (DME), including delivery and setup.
The patient must sign, or a representative, the patient’s spouse, or another family member age 18 or older may sign on the patient’s behalf. A nurse or case manager may also sign.
Once the item is delivered, EWMS can send the proof of delivery form by text or email to the preferred eligible signer.
Proof of Delivery Contact Preference (individual and contact method):
Please provide EWMS with the eligible signer’s name, relationship to the patient, preferred contact method (text or email), and mobile number or email address. If your online form does not include these fields, call (801) 841-4490 to share your preference.
Available Patient Forms
Equipment evaluations, agreements, intake forms, and special request forms ready for patients.
Request
Non-PA Request Item Form
Request form for items that do not require prior authorization.
Evaluation
Air Purifier Eval
Evaluation form for air purifier equipment requests.
Evaluation
Exercise Equipment Eval
Evaluation form for exercise equipment requests.
Evaluation
Handrail Eval
Evaluation form for handrail equipment requests.
Evaluation
Hospital Bed Eval
Evaluation form for hospital bed requests.
Evaluation
Lift Recliner Eval
Evaluation form for lift recliner requests.
Options
Lift Recliner Options
Options form for lift recliner selections.
Evaluation
Misc Item Eval
Evaluation form for miscellaneous equipment requests.
Evaluation
Noninvasive Ventilator Eval
Evaluation form for noninvasive ventilator requests.
Evaluation
Nutritional Supplement Eval
Evaluation form for nutritional supplement requests.
Evaluation
Oxygen Eval
Evaluation form for oxygen equipment requests.
Evaluation
Patient Lift Eval
Evaluation form for patient lift equipment requests.
Evaluation
Scooter Eval
Evaluation form for scooter equipment requests.
Evaluation
Scooter Lift Eval
Evaluation form for scooter lift equipment requests.
Evaluation
Ramp Eval
Evaluation form for ramp equipment requests.
Agreement
ONO Test Agreement
Agreement form for overnight oximetry testing.
Patient Intake
New Patient Info and HIPAA
Supplemental new patient information and HIPAA form.
Patient Intake
Patient Bill of Rights
Patient Bill of Rights acknowledgment form.
Patient Intake
New Patient Info
Supplemental new patient information form.
Patient Intake
HIPAA Form
HIPAA acknowledgment and information form.
Evaluation
Compression Sock Evaluation
Evaluation form for compression sock requests.
Need help with a form?
Our team can help you choose the right form or answer questions.
(801) 841-4490
All forms are protected and fully HIPAA-compliant.