DME Information Form CMS-10126-Enteral and Parenteral Nutrition 2026

1. Click ‘Get Form’ to open the DME Information Form CMS-10126 in the editor.
2. Begin by filling out the Certification Type/Date section. Indicate whether this is an initial or revised certification by entering the appropriate dates.
3. Complete the Patient Information section with the patient's name, address, telephone number, and Medicare ID as it appears on their card.
4. In the Supplier Information section, enter your company 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 different service locations.
6. List all Supply Item/Service Procedure Codes relevant to the items ordered in the designated area.
7. Fill in patient details such as date of birth, height, weight, and sex in the Patient DOB section.
8. Provide Physician Information including their name, address, and contact details along with their UPIN or NPI number.
9. Answer all questions in the Question Section accurately by checking 'Y' for Yes or 'N' for No as applicable.
10. Finally, complete the Supplier Attestation by signing and dating the form to certify that all information provided is accurate.

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