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Dme certification and receipt form

Dme certification and receipt form 2025

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The DME Certification and Receipt Form is a required document for Medicaid clients to certify the provision of durable medical equipment (DME) by providers. It includes sections for client and provider information, product details, and certification of proper fitting and training on equipment use. The form must be completed before payment can be processed for DME services, particularly for high-cost items or wheeled mobility systems. It also includes instructions for clients regarding verification calls.

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Click ‘Get Form’ to open the DME Certification and Receipt Form in the editor.
Begin with Section A: Client Information. Fill in the client's name, address, telephone number, Medicaid ID number, city, state, and alternate telephone number.
Proceed to Section B: Provider Information. Enter the provider's name, NPI/API, prior authorization number (PAN), and TPI.
In Section C: Product Information, input the date of service and procedure codes for each item. Provide descriptions and serial numbers for all equipment being certified.
Complete Section D: Certification by certifying that the client received the prescribed equipment. Ensure signatures from both the DME supplier and client or caregiver are included.
If applicable, continue to Section E for Qualified Rehabilitation Professional (QRP) verification. Fill in necessary details and ensure proper signatures are obtained.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (90 Votes)
2011	4 Satisfied (44 Votes)
2011	4.9 Satisfied (51 Votes)

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