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Attentive Medical Supply
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Provider Referrals
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Rentals & Repairs
DME & HME Products
Attentive Medical Supply
Home
Provider Referrals
Patients
Rentals & Repairs
DME & HME Products
More
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Provider Referrals

SECURE UPLOAD

Healthcare Provider Referral Instructions

SUBMIT PATIENT REFERRALS

Fax: 704-781-5502


Phone: 704-781-5632


Secure Email: admin@attentivemedicalsupply.com


Electronic healthcare provider referrals are available through:


DMEconnected

Parachute Health


We also offer a wide range of medical supplies to assist with patient referrals.

DOWNLOAD FORMS

Fax Coversheet


Prescription / Standard Written Order


Phyisican's Notes/Medical Records from Patient's last face-to-face visit


Completed CMN/PA 

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Add "Attentive" after your Practice Name when registering. 


FREE registration. Connects to EPIC.

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Required Documents Prior to Dispensation

Physician's notes and medical records from the patient's last face-to-face visit, which must be within 6 months of the date of prescription, are essential for healthcare provider referrals and to ensure the appropriate medical supplies are available for patient referrals.

Attentive_Medical_Fax_Coversheet - Providers (pdf)Download
Standard Written Order Form (pdf)Download
Hospital_Bed_CMN Form (pdf)Download
Manual Wheelchair_CMN Form (pdf)Download
Request for Prior Approval CMNPA (NC Medicaid-372-131) (pdf)Download
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Attentive Medical Supply

12925 Highway 601 South, Ste 100, Midland, NC 28107

Phone: 704-781-5632

Copyright © 2026 Attentive Medical Supply - All Rights Reserved.

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