Address mail 2026

1. Click ‘Get Form’ to open the address mail document in the editor.
2. Begin with Section A by entering the Certification Type and Date. Choose between 'INITIAL' or 'REVISED' and fill in the corresponding dates.
3. Fill in the Patient Information, including their name, address, telephone number, and Health Insurance Claim Number (HICN).
4. Next, provide Supplier Information by entering your company name, address, telephone number, and National Supplier Clearinghouse (NSC) number.
5. Indicate the Place of Service where the item will be used. If applicable, include the Facility Name and Address.
6. Complete Section B by estimating the Length of Need in months and listing Diagnosis Codes (ICD-9) relevant to the patient's condition.
7. Answer all questions regarding medical necessity by circling 'Y', 'N', or 'D' as appropriate for each item listed.
8. In Section C, provide a Narrative Description of Equipment and Cost detailing all items ordered along with their charges.
9. Finally, Section D requires the Physician's Attestation. The physician must sign and date this section to certify accuracy.

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