Fillable Printable Letter of Intent for Durable Medical Equipment and Suppliers
Fillable Printable Letter of Intent for Durable Medical Equipment and Suppliers
Letter of Intent for Durable Medical Equipment and Suppliers
If you are applying to enroll as a MassHealth provider of durable medical equipment (DME) and medical supplies, or if you are currently
enrolled with MassHealth as a pharmacy provider or oxygen and respiratory therapy equipment provider, and are requesting a DME
specialty for your existing MassHealth provider file, you must submit a Letter of Intent (LOI) (see below). In accordance with 130 CMR
409.404, you must submit the LOI to MassHealth before receiving and completing a MassHealth provider application for DME. You must
submit a separate LOI for each service facility for which you are applying to become a MassHealth DME provider, or for which you are
requesting a DME specialty. Submit your completed and signed LOI to the following address
MassHealth
Attention: Provider Enrollment and Credentialing
P.O. Box 9162
Canton, MA 02021
MassHealth may request additional information from the applicant after receiving the completed LOI form. MassHealth must receive a
fully completed LOI from the applicant within 14 calendar days of the applicant’s request to enroll as a MassHealth DME provider. If any
information on the LOI needs further clarification, or is not deemed sufficient, a notification will be sent to the applicant requesting the
additional information be sent to MassHealth, within 10 business days of the date of the notification. Please note that MassHealth cannot
process a provider application for DME until a fully completed LOI is received. Once the completed LOI is received by MassHealth, the
applicant will receive a letter from MassHealth acknowledging receipt of the LOI and informing the applicant to proceed with submitting a
provider application to MassHealth.
Please Note: If you are planning to provide home infusion services, you must first enroll as a MassHealth pharmacy provider. This must be
done before submitting an LOI and application to MassHealth to provide DME services.
1. Applicant’s tax ID no.:
Legal entity name:
Legal entity address:
Doing business as (DBA) name:
DBA address (i.e., service facility address):
Contact name: E-mail address:
Phone no.: Fax:
If you are currently enrolled as a MassHealth provider, list all your MassHealth provider ID nos.:
2. What is your organization/company’s current primary scope of business (i.e., mobility equipment and accessories)?
3. Do you have a pharmacy license? Yes No If yes, license no.:
Note: Except for specialty providers described in 130 CMR 409.404(D), the applicant (and if it becomes a provider, the DME
provider) must primarily engage in the business of providing DME or durable medical equipment repair services to the public.
For example, an applicant or provider with a pharmacy license would not be considered primarily engaged in the business
of providing DME.
LOI-DME (Rev. 05/14)
(over ►)
Letter of Intent for Durable
Medical Equipment and Supplies
4. What DME services, equipment, and/or medical supplies do you intend to provide to MassHealth members?
5. List the address for each service facility location operated by your organization/company.
6. List the service facility DBA address for which this LOI applies and for which you are applying to be a MassHealth provider of DME.
Note: DME regulations at 130 CMR 409.404(C)(2) require separate approval from MassHealth, and a separate provider number
for each service facility DBA address operated by the provider.
7. Describe the geographical area(s) in which you intend to provide the above services.
8. Do you intend to use a subcontractor(s)? Yes No
9. If you answered “Yes” to question 8, provide the name and address of the subcontractor(s), and describe the specific services,
equipment, or supplies for which you intend to subcontract. If you answered “No” to question 8, indicate N/A here.
10. List the existing contracts you have with other third-party payers. You must also update MassHealth immediately with any
new, terminated, or expired contracts.
Attestation, Signature, and Date
I hereby certify under the pains and penalties of perjury that the information on this form, and any attachments that I have provided,
have been reviewed and are true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties
or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. I have read the MassHealth
regulations and understand and agree that it is my responsibility to be familiar and comply with the provisions of those regulations as they
currently appear and as they may at any time be modified.
Signature of DME applicant:
(Signature and date stamps, or the signature of anyone other than the applicant or a person legally authorized to sign on behalf of a legal
entity, are not acceptable.)
Printed legal name of DME applicant:
Printed legal name and position/title of individual signing:
(if the applicant is a legal entity)
Contact information of individual signing:
Address: E-mail:
Phone: Fax:
Date:
