Code Verification Request Application Instructions
If required information is missed or not completed, the application may be rejected and a new application must be submitted with all required information.
See Required Indicator column to verify if item is required.
- Section A – Manufacturer Information
o A.1 Manufacturer Information
o A.2 Distributor Information
o A.3 Consultant/Designated Representative Information - Section B – Product Information
o Product Description and Details
o HCPCS Codes - Section C – Product Specific Information
o Compression Garments
o Enteral Nutrition Formula
o Manual Wheelchairs
o Power Wheelchairs and Power Operated Vehicles
o Orthotics
o Oral Appliances for Obstructive Sleep Apnea
o Support Surfaces
o Surgical Dressings
o Therapeutic Shoes and Inserts for Diabetics
o Wheelchair Cushions (Backs and Seats) - Section D – Authorized Signature
- Submit an Application
Select all statements and options that apply to product being submitted:
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| 1. The product has never been code reviewed by the PDAC | Check box for a new product, not previously coded by PDAC. |
If applicable* |
| 2. The product was submitted for code review but the application was rejected |
Check box for a product previously submitted for review in which application was rejected. |
If applicable* |
| 3. The product was code reviewed by the PDAC over 45 days ago |
Check the box for a product previously reviewed by PDAC in which 45-day timeframe for submitting a reconsideration has lapsed. Provide DCN from previous application(s). |
If applicable* |
| 4. The Product has been modified in part or in whole since code reviewed by the PDAC | Check the box for a previously reviewed product that has been modified since initial review. |
If applicable* |
| 5. The product was code reviewed by the PDAC but the following has changed | Check appropriate boxes [CHANGE IN MANUFACTURER NAME, CHANGE IN PRODUCT NAME/CHANGE IN MODEL NUMBER(S)/ADDITION TO MODEL NUMBER(S)/PRIVATE LABEL AGREEMENT]. | If applicable* |
| If selected statements 2, 3, 4, or 5 provide Document Control Number(s) (DCN) from previous application(s) | Provide DCN from previous application(s) if statements 2 through 5 are selected. | If applicable* |
*One of the options listed above must be selected in order to process the application.
Section A – Manufacturer Information
A.1 Manufacturer Information
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Manufacturer Name |
Enter the legal manufacturer's name. |
YES |
| Manufacturer Point of Contact |
Enter the manufacturer contact person's name. This contact will be sent all correspondence and contacted during the review process if needed. |
YES |
| Email Address |
Enter the manufacturer point of contact's email address. |
YES |
| Telephone Number |
Enter the manufacturer point of contact's telephone number. |
YES |
| Mailing Address (City, State, Zip) (Country, if other than US) |
Enter the manufacturer point of contact's mailing address. |
YES |
| Website Address |
Enter the manufacturer's website address. |
YES |
| Most Current Year of Registration | Enter most current year of registration for product from FDA correspondence. It must be current year of submission of Code Verification Review Application. | YES |
| Establishment Registration Number |
Enter Establishment Registration Number for product. A copy of email or letter confirmation provided from FDA or screen shot from FDA’s website containing manufacturer name, product name, registration number, and current registration year MUST be included with application. |
YES |
A.2 Distributor Information
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Distributor Name | Enter the legal distributor’s name. |
If applicable* |
| Distributor Point of Contact | Enter the distributor contact person’s name. This contact will be sent all correspondence and contacted during the review process if needed. |
If applicable* |
| Email Address | Enter the distributor point of contact’s email address. | If applicable* |
| Telephone Number | Enter the distributor point of contact’s telephone number. | If applicable* |
| Mailing Address (City, State, Zip) (Country, if other than US) | Enter the distributor point of contact’s mailing address. | If applicable* |
| Website Address | Enter the distributor’s website address. | If applicable* |
| Most Current Year of Registration | Enter most current year of registration for product from FDA correspondence. It must be current year of submission of Code Verification Review Application. | If applicable* |
| Establishment Registration Number |
Enter Establishment Registration Number for product. A copy of email or letter confirmation provided from FDA or screen shot from FDA’s website containing distributor name, product name, registration number, and current registration year MUST be included with application. View information on US FDA Establishment Registration & Device Listing webpage for more information along with Who Must Register. |
If applicable* |
A.3 Consultant/Designated Representative Information
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Consultant/Representative Name | Enter the legal consultant or representative name. |
If applicable* |
| Company Name | Enter the company name of the consultant or representative. | If applicable* |
| Email Address | Enter the consultant’s or representative’s email address. | If applicable* |
| Telephone Number | Enter the consultant’s or representative’s telephone number. | If applicable* |
| Mailing Address (City, State, Zip) | Enter the consultant’s or representative’s mailing address. | If applicable* |
| Website Address | Enter the consultant’s or representative’s website address. | If applicable* |
Section B – Product Information
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Manufacturer/Distributor Name | Enter the Manufacturer or Distributor’s Name as it will be listed on the Product Classification List (PCL). If the Distributor’s name is to be associated with the product, provide documentation supporting the relationship with the manufacturer. | YES |
| Product Name |
Enter the Product Name as it will appear on the PCL. |
YES |
| Model Number(s) |
Enter the model number(s) of product submitted for coding. This is the model number that will be listed on the PCL. Enter ‘None’ if there is no model number associated with the product. If there are multiple model/part numbers for the product, provide a base model number to be listed on the PCL. Place holders can be used for size, color, etc. options. Example: Base-XX where XX indicates size. Note: Verify accuracy of model number(s) product name as it will be listed on the PCL. Any errors in the submitted number(s) name to be corrected will require submission of another code verification review application.
|
YES |
| Does product need a PCL Comment for Model Number Explanation to clarify size, color, or height? |
Check appropriate box [YES/NO] if product needs a PCL comment for the model number. Often manufacturers request clarifying comments be posted to the PCL to clarify model number format and differences between model numbers. Indicate if your product needs a Comment for Model Number loaded to the PCL. |
YES |
| If yes, provide comment to be entered in DMECS |
Enter the comment to be posted on the PCL providing additional information for product submitted. Example: XX AND YY WITHIN THE MODEL NUMBER ARE PLACEHOLDERS FOR HEIGHT (XX) AND WIDTH (YY) |
NO |
| Is a product sample required to be submitted per instructions on the PDAC Website? | Check appropriate box [YES/NO] if product sample is required. List of product sample requirements can be found here. |
YES |
| Is a product sample being submitted with this application? | Check appropriate box [YES/NO] if product sample is being submitted with application. | YES |
Product Description and Details
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Product Status? | Check appropriate box [MARKET/PRE-MARKET] of current status of submitted product. Pre-Market indicates that the product is not available for sale. | YES |
| Is this product for home use? |
Check appropriate box [YES/NO] if product is for home use. Per the Social Security Act Title XVIII Section 1861(n), all products must be able to be used in home to qualify for payment by Medicare. |
YES |
| FDA Device Classification | Check appropriate box [CLASS I/CLASS II/CLASS III] of the classification of product | YES |
| FDA 510(K) Number or FDA Exemption Regulation Number if Exempt |
Enter FDA 510(K) number or Exemption Regulation Number if 510(K) exempt. If 510(K) manufacturer does not match submitter, documentation must be provided explaining relationship. Note: Must submit a copy of letter |
YES |
| Provide a detailed and complete description of the product. Include all functional information and any manufacturing information that supports requested code(s) |
Enter a detailed and complete description of product including all functional and manufacturing information that supports requested code(s). Note: Referring to a manual, guide or attached documents without providing a written narrative on application will not be accepted for a detailed and complete description of product. |
YES |
| List all component(s) that are standard that are included in base product (i.e. power cords, batteries, arm rests, etc.), if applicable |
If the product submitted is considered a base code and includes additional components, list all items included with base product when provided to beneficiary. *Required if submitting an application for DME Supplies and Manual Wheelchairs. |
NO* |
| Does this product carry a warranty? | Check appropriate box [YES/NO] if product comes with a warranty. | YES |
| Type/Duration | Enter type of warranty and duration (e.g. Service Life) | YES |
| Specify minimum expected lifetime for the equipment in months and/or years | Enter the minimum expected lifetime for the product in months and/or in years. | YES |
HCPCS Code(s)
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| List HCPCS Code(s) requested for product(s) and a detailed justification for code(s) being selected |
List the desired HCPCS code(s) for product(s) submitted for review and provide a justification for each requested HCPCS code. If unsure what HCPCS code(s) to request, enter “UNSURE” in HCPCS Code Field and leave justification blank. If additional room is needed attach documentation and indicate it in the application. |
YES |
| List HCPCS Code(s) requested for accessory/supply and detailed justification for code(s) being selected |
List the desired HCPCS code(s) for accessories or supplies associated with product and provide a justification for each requested HCPCS code. If unsure what HCPCS code(s) to request, enter “UNSURE” in HCPCS Code Field and leave justification blank. If additional room is needed attach documentation and indicate it in the application. |
If applicable* |
| If previously coded by other insurers or agencies, provide code(s) assigned | Enter if the product(s) has/have been coded by another payer and provide the code that was assigned. | NO |
Section C – Product Specific Information
Prior to completing Section C and submitting the coding verification application, review all appropriate DME MAC policy related material (DME MAC LCD, coding and policy articles, etc.).
Locate, complete and attach Section C for the product type being submitted. This is located at dmepdac.com. Section C must be attached or the application will be rejected.
Prostheses, orthopedic footwear, and DME accessory applications are not required to submit a Section C. Attach any additional documentation and/or photographs to support your requested code.
For Power Mobility Devices and Power Wheelchairs attach the RESNA testing results form. This is located at dmepdac.com. The form is required. The application will be rejected if it is not attached.
Be sure to complete and include applicable Section C.
- Compression Garments
- Enteral Nutrition Formula
- Manual Wheelchairs
- Orthotics
- Oral Appliances for Obstructive Sleep Apnea
- Support Surfaces
- Surgical Dressings
- Therapeutic Shoes and Inserts for Diabetics
- Wheelchair Cushions (Backs and Seats)
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Garment Location | Check appropriate box of location garment is applied. Options: ARM, BRA, FOOT, GAUNTLET, GENITAL, GLOVE, LEG, SHOULDER, THIGH, TOE, TORSO, WAIST, OTHER. (Provide location if other is marked). | YES |
| Is the compression garment for nighttime use? | Check appropriate box [YES/NO] if garment is used at night. | YES |
| Is the compression garment custom? | Check appropriate box [YES/NO] if garment is custom. | YES |
| If custom, indicate the minimum number of circumferential measurements taken. | Enter the minimum number of circumferential measurements that need to be taken in order to produce a custom final product. | YES |
| Where applicable, list all pressure ranges of the product. | Enter the applicable pressure ranges for the product. Testing documentation MUST be provided to validate specified ranges. | YES |
| Is this product also used as a surgical dressing? | Check appropriate box [YES/NO] if garment is used as a surgical dressing. | YES |
| If also requesting a surgical dressing HCPCS code for this product be certain to include a completed copy of the Section C - Surgical Dressings form with your application. | Informational only: When requesting that a compression garment also be considered as a surgical dressing, the related Section C form must be submitted to detail its material composition. | NO |
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| List all indications |
Enter all medical conditions for which formula is used. |
YES |
| Method of Administration | Check appropriate box [ORAL ONLY/TUBE ONLY/ BOTH ORAL AND TUBE] of how formula is administered. | YES |
| Administered to | Check appropriate box [PEDIATRIC/ADULT/BOTH PEDIATRIC AND ADULT] to whom formula is administered. | YES |
| Does formula include carbohydrates? | Check appropriate box [YES/NO] if formula includes carbohydrates. | YES |
| Does formula include fats? | Check appropriate box [YES/NO] if formula includes fats. | YES |
| Does formula include proteins? | Check appropriate box [YES/NO] if formula includes proteins. | YES |
| Does formula include hydrolyzed proteins? | Check appropriate box [YES/NO] if formula includes hydrolyzed proteins. | YES |
| If yes, list all hydrolyzed proteins | List all hydrolyzed proteins included in formula. | NO |
| Does formula include minerals? | Check appropriate box [YES/NO] if formula includes minerals. | YES |
| Does formula include vitamins? | Check appropriate box [YES/NO] if formula includes vitamins. | YES |
| Is product a blenderized natural food? | Check appropriate box [YES/NO] if formula includes blenderized natural foods. | YES |
| Is product calorically dense? | Check appropriate box [YES/NO] if product is calorically dense. | YES |
| Provide KCAL/ML for calorically dense formula | Enter amount of formula in KCAL/ML. | YES |
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Does this product carry a warranty? | Check appropriate box [YES/NO] if this product carries a warranty. | YES |
| If Yes, provide duration of warranty |
Enter amount of time for warranty. |
NO |
| Does this product meet three-year Minimum Lifetime Requirement? | Check appropriate box [YES/NO] if product meets three-year minimum lifetime requirement. The DME definition in CFR 414.202 requires all DME to have a three-year minimum lifetime. | YES |
| Does this chair come with a back and seat? | Check appropriate box [YES/NO] if wheelchair comes with a back and a seat. | YES |
| Provide following product measurements and unit measure for each | Enter measurement for seat width and depth in inches. Enter measurements for back width and height in inches. | YES |
| Description of back | Check appropriate description [FIXED/ADJUSTABLE/HIGH/STANDARD] of back. | YES |
| Weight of manual wheelchair without front riggings | Enter weight of chair without front riggings, in pounds. | YES |
| For transport chair (E1038, E1039), provide patient weight capacity | Enter patient weight capacity if requesting a transport chair (HCPCS E1038 or E1039), in pounds. | NO |
| For all other manual wheelchairs, provide weight capacity | Enter weight capacity of wheelchair in pounds, if requesting a code other than HCPCS E1038 or E1039, in pounds. | NO |
| Provide degree of tilt |
Enter degree of tilt, if requesting a code for a wheelchair with tilt. |
NO |
| Provide the degree of recline | Enter degree of recline, if requesting a code for a wheelchair with recline. | NO |
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
|
How is this product sampled? Important Note: If choosing both Off-The-Shelf and Custom Fitted both codes must be requested in Section B of application |
Check appropriate box [OFF-THE-SHELF/CUSTOM FITTED/BOTH OFF-THE-SHELF AND CUSTOM FITTED/CUSTOM FABRICATED] how product is supplied. | YES |
| Provide a list of materials and a description of orthosis | List all material(s) used in product and provide a detailed description of orthosis. | YES |
| If product is custom fabricated, a step-by-step description of fabrication process must be provided. Include color photographs of each step within the fabrication process |
Provide a detailed step-by-step description of custom fabrication process. Include color photographs of each step within fabrication process. *Required only if product is custom fabricated. |
NO* |
Oral Appliances for Obstructive Sleep Apnea
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Is the product custom fabricated? | Check appropriate box [YES/NO] if product is custom fabricated. | YES |
| If Yes, provide information on how the impression of the beneficiary’s teeth is made and how the device is fabricated. | Provide detailed information how impression is made of beneficiary’s teeth and how the device is fabricated. Pictures of both processes are highly recommended. | NO |
| If product is custom fabricated, a step-by-step description of fabrication process must be provided. Include color photographs of each step within the fabrication process |
Provide a detailed step-by-step description of custom fabrication process. Include color photographs of each step within fabrication process. *Required only if product is custom fabricated. |
NO* |
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Does this product meet three-year Minimum Lifetime Requirement? | Check appropriate box [YES/NO] if product meets three-year minimum lifetime requirement. The DME definition in CFR 414.202 requires all DME to have a three-year minimum lifetime. | YES |
| Does support surface have a durable, waterproof cover? | Check appropriate box [YES/NO] if product has a durable, waterproof cover. | YES |
| Can support surface be placed directly on a hospital bed frame? | Check appropriate box [YES/NO] if product can be placed on a hospital bed frame. | YES |
| Can support surface be placed on top of a mattress? | Check appropriate box [YES/NO] if product can be placed on top of a mattress. | YES |
| Is surface designed to reduce friction and shear? | Check appropriate box [YES/NO] if product is designed to reduce friction and shear. | YES |
| Is there adequate patient lift to prevent bottoming out? | Check appropriate box [YES/NO] if product prevents patient from bottoming out. | YES |
| Provide the measurements of overall product |
Enter product length, width and height in inches in appropriate box. |
YES |
| Provide the type of Support Surface | Check appropriate box [FOAM/GEL/ AIR/OTHER] for type of support surface (provide description if other is marked). | YES |
| Provide the cycle time for product |
Enter the cycle time for the product in minutes. *Required for Air Support Surface Only. |
NO* |
| Provide height of the air cells when inflated |
Enter the height of the air cells, in inches, when fully inflated. *Required for Air Support Surface Only. |
NO* |
| Provide the number of cells |
Enter the number of air cells in the support surface. *Required for Air Support Surface Only. |
NO* |
| Provide height of gel bladders |
Enter the height of the gel bladders in support surface. |
NO* |
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| List all components in dressings along with weight and percentage of each component |
Enter all components in dressing. Include weight and percentage of composition for each listed component. Total percentage of all components MUST equal 100%. Do not include packaging in list of components. |
YES |
Therapeutic Shoes and Inserts for Diabetics
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Is insert molded directly to beneficiary’s foot immediately following use of an external heat source (excluding heat sources commonly used as commercial hand-held hair dryers) that can produce heat at temperatures of 230° or greater? |
Check appropriate box [YES/NO] if insert is molded directly to patient’s foot immediately following use of an external heat source. *Only Required for Prefabricated Therapeutic Inserts. |
YES* |
| Is insert molded by use of “compression molding” (molding via beneficiary’s weight and body heat) without use of an external heat source? |
Check appropriate box [YES/NO] if insert is molded using compression molding. *Required if previous question is no and for Prefabricated Therapeutic Inserts. |
YES* |
| Provide shore A durometer measurement of base material (for requested HCPCS A5512) |
Enter shore A durometer measurement of base material for requested HCPCS A5512 |
YES* |
| Is insert molded directly to a physical positive model of beneficiary’s foot? |
Check appropriate box [YES/NO] if insert is molded directly to a physical positive model of beneficiary’s foot. |
YES* |
| Is insert a direct carved/milled from a rectified virtual model of the beneficiary’s foot? |
Check appropriate box [YES/NO] if insert is directly carved/milled from a digital scan of the beneficiary’s foot? *Only Required for Custom Fabricated Therapeutic Inserts. |
YES* |
| Provide shore A durometer measurement of base material (for requested HCPCS A5513 and A5514) |
Enter shore A durometer measurement of base material for requested HCPCS A5513 and A5514. *Only Required for Custom Fabricated Therapeutic Inserts. |
YES* |
| Step-by-step description of fabrication process MUST be provided. Include color photographs of each step within fabrication process |
Provide a step- by-step description of fabrication process MUST be provided. Include color photographs of each step within fabrication process. Attach additional sheets if necessary. *Only Required for Custom Fabricated Therapeutic Inserts. |
YES* |
| Are there 3 or more widths available for each product line? |
Check appropriate box [YES/NO] if there are three or more widths. |
YES* |
| Does the shoe come in half sizes? |
Check appropriate box [YES/NO] if shoes come in half sizes. |
YES* |
| Is the shoe molded directly to a positive model of beneficiary’s foot? |
Check appropriate box [YES/NO] if shoe molded directly to a positive model of beneficiary’s foot. *Only Required for Custom Modeled Therapeutic Shoes. |
YES* |
| Is the shoe made from leather or other suitable material of equal quality? |
Check appropriate box [YES/NO] if shoe made from leather or other suitable material of equal quality. *Only Required for Custom Modeled Therapeutic Shoes. |
YES* |
| Does the shoe have removable inserts that can be altered or replaced as beneficiary’s condition warrants? |
Check appropriate box [YES/NO] if shoe has removable inserts that can be altered or replaced as beneficiary’s condition warrants. *Only Required for Custom Modeled Therapeutic Shoes. |
YES* |
| Does the shoe have some form of closure? |
Check appropriate box [YES/NO] if shoe has some form of closure. |
YES* |
| Step-by-step description of fabrication process MUST be provided. Include color photographs of each step within fabrication process |
Provide a step-by-step description of fabrication process MUST be provided. Include color photographs of each step within fabrication process. Attach additional sheets, if necessary. |
YES* |
Wheelchair Cushions (Backs and Seats)
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Does product have a permanent label with manufacturer name and model number and/or product name? | Check appropriate box [YES/NO] if product has a permanent label with manufacturer name and model number and/or product name listed. | YES |
| Does this product have a warranty for repair or a full replacement of manufacturer defects? | Check appropriate box [YES/NO] if product has a warranty for repair or a full replacement for the defects. | YES |
| If Yes, provide length of warranty |
Check appropriate box [12 MONTHS/18 MONTHS/OTHER] if product has a warranty. If “OTHER” is checked, enter amount of time for warranty, in months. |
NO |
| Does this product have one of the following surface or cover types? |
Check appropriate box [YES/NO] if product has one of surface types listed:
|
YES |
| Does cushion and cover meet California Bulletin 117 or 133 for fire retardant properties or equivalent test? |
Check appropriate box [YES/NO] if product meets California Bulletin 117 or 133 for fire retardant properties or equivalent test. |
YES |
| Indicate type of testing methodology performed on product | Check appropriate box [SIMULATION TEST/HUMAN SUBJECT] for testing methodology. The test report for product on this application must be submitted. For testing requirements, see Wheelchair Seating Local Coverage Determination (LCD) and Policy Article. | YES |
| Provide type of wheelchair seat or back cushion |
Check appropriate box [FOAM/GEL/ AIR/OTHER] for type of seat or back cushion. If “OTHER” is checked, enter a description. |
YES |
| Is wheelchair cushion adjustable based on the Local Coverage Determination Coding Guideline requirements? | Check appropriate box [YES/NO] if product is adjustable based on requirements. | YES |
| If Yes, describe how cushion meets requirements | If “YES” was checked in previous box, provide a description on how cushion meets requirements in policy. | NO |
| List all components and accessories included in base product | Enter all items that are included with wheelchair seat or back when provided to beneficiary. | YES |
| Is cushion fabricated for a specific beneficiary starting with basic materials? |
Check appropriate box [YES/NO] if cushion is fabricated for a specific beneficiary starting with basic materials. *Only required for Custom Fabricated Cushions. |
YES* |
| Is it fabricated using molded-to-beneficiary-model technique, direct molded-to-beneficiary technique, CAD-CAM technology, or detailed measurements of beneficiary used to create a configured cushion? |
Check appropriate box [YES/NO] if cushion is fabricated using molded-to-beneficiary-model technique, direct molded-to-beneficiary technique, CAD-CAM technology, or detailed measurements of beneficiary used to create a configured cushion. *Only required for Custom Fabricated Cushions. |
YES* |
| Does the cushion have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion? |
Check appropriate box [YES/NO] if cushion has structural features that significantly exceed minimum requirements for a seat or back positioning cushion. *Only required for Custom Fabricated Cushions. |
YES* |
| Step-by-step description of fabrication process MUST be provided. Include color photographs of each step within fabrication process |
Provide a step-by-step description of fabrication process. Include color photographs of each step within fabrication process. *Only required for Custom Fabricated Cushions. |
YES* |
Section D – Authorized Signature
| Requested Information | Completion Instructions | Required Indicator |
|---|---|---|
| Company | Enter authorized company. | YES |
| Authorized Official Name |
Print authorized official’s name. |
YES |
| Authorized Official Title |
Enter authorized official’s title. |
YES |
| Signature |
Signature of authorized official. |
YES |
| Date |
Enter date form was signed. |
YES |
Submit an Application
If no product sample is required, a completed application can be submitted via email to PDAC.APPLICATION@palmettogba.com, faxed, or mailed to the address below:
Fax Number: (803) 264-0648
Palmetto GBA
Attn: PDAC
PO Box 100320
Columbia, SC 29202-3320
If product samples are required, a completed application and product samples must be mailed to:
Palmetto GBA
Attn: PDAC
AG-440
2300 Springdale Drive, Building One
Camden, SC 29020-1728
- See Product Sample Requirements webpage for a list of required product samples.
- All product samples will be held for 60 days from date on rejection notice.
- If new application is submitted after 45 days, a new product sample MUST be submitted.
- Enter DCN number from rejection notice at the top of application form, if not entered, application processing may be delayed.