Map1000 2025

1. Click ‘Get Form’ to open the map1000 in the editor.
2. Begin by filling out Section A, entering the Certification Type and Date. Provide the Patient's Name, Address, Telephone, and Member Number, along with Supplier details.
3. In Section B, input the Patient's Information. Note that this section cannot be completed by the supplier. Fill in the Estimated Length of Need and Diagnosis with Codes.
4. Continue in Section B by detailing the type of equipment ordered and its duration of need. Indicate if the patient is confined to bed and provide relevant dates.
5. Move to Section C to describe all items ordered, including costs and Medicare Fee Schedule Allowance for each item.
6. Finally, complete Section D with the Physician's Attestation. Ensure you sign and date this section as required.

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