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- Click ‘Get Form’ to open the hcfa 843 form in the editor.
- Begin with Section A. Fill in the Certification Type/Date by selecting either 'INITIAL' or 'REVISED' and entering the appropriate dates.
- Enter the Patient's information, including name, address, telephone number, and HIC number as it appears on their Medicare card.
- Provide Supplier Information by filling in your company name, address, telephone number, and NSC number.
- In Section B, indicate the Estimated Length of Need and fill in Diagnosis Codes (ICD-9) relevant to the patient's condition.
- Answer questions regarding medical necessity by circling 'Y', 'N', or 'D' as applicable for each item listed.
- Complete Section C with a narrative description of equipment and costs associated with items ordered.
- Finally, Section D requires the physician's signature and date to certify that all information is accurate and complete.
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