Form CMS-847 - CMS.gov 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, fill in the Certification Type/Date by selecting whether this is an Initial, Revised, or Recertification. Enter the patient’s name, address, telephone number, and Medicare ID.
3. Provide your supplier information including name, address, telephone number, and either NSC or NPI number. Specify the Place of Service and list the Supply Item/Service/Procedure Code(s).
4. Complete patient details such as Date of Birth, Sex, Height, and Weight. Then enter the Physician's information including name, address, telephone number, and UPIN or NPI.
5. In Section B, indicate the Estimated Length of Need and fill in Diagnosis Codes. Answer questions 6-12 based on the patient's condition by checking 'Y', 'N', or 'D'.
6. Section C requires a narrative description of equipment and costs from the supplier. Finally, in Section D, ensure that the physician signs and dates to certify all provided information.

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