Dme information form 2025

1. Click ‘Get Form’ to open the DME Information Form in the editor.
2. Begin by filling out the Certification Type/Date section. Indicate whether this is an initial certification, a revised one, or a recertification by entering the appropriate dates.
3. Next, provide the Patient Information. Enter the patient's name, address, telephone number, and Medicare ID as it appears on their card.
4. In the Supplier Information section, input your company’s name, address, telephone number, and either your NSC or NPI number.
5. Specify the Place of Service where the item will be used. Use appropriate codes for locations such as home or skilled nursing facilities.
6. List all Supply Item/Service Procedure Codes that require certification in the designated area.
7. Fill in patient details including date of birth, height, weight, and sex.
8. Provide the Physician's Name and complete address along with their UPIN or NPI number.
9. Answer questions 1–4 regarding external infusion pumps accurately by checking 'Y' for yes or 'N' for no as applicable.
10. Finally, sign and date the Supplier Attestation to certify that all provided information is accurate before submitting your form.

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