Form online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A: Client Information. Fill in the required fields such as Name, Medicaid ID Number, Address, City, Telephone Number, State, and ZIP. Ensure all mandatory fields marked with an asterisk (*) are completed.
3. Proceed to Section B: Provider Information. Enter details like Provider Name, Prior Authorization Number (PAN), NPI/API, Taxonomy, and Benefit Code. Complete the Street Address, City, State, and ZIP + 4.
4. In Section C: Product Information, document the Date of Service and Procedure Codes along with their corresponding Descriptions and Serial Numbers for each item provided.
5. Move to Section D: Certification. Certify that the client received the equipment by filling in the date and equipment description. Ensure signatures from both the DME supplier and client or caregiver are included.
6. If applicable, complete Section E for Qualified Rehabilitation Professional (QRP) Verification by providing necessary details and signatures.

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