Cms 84 fillable form 2026

1. Click ‘Get Form’ to open the cms 84 fillable form in the editor.
2. Begin with Section A. Fill in the Certification Type/Date by selecting whether it is an Initial, Revised, or Recertification. Enter the patient’s name, address, telephone number, and HIC number.
3. Next, provide the Supplier's information including name, address, telephone number, and NSC or NPI number. Specify the Place of Service and Facility Name if applicable.
4. In Section B, enter the HCPCS codes for items ordered. Complete the physician's details including name, address, and NPI or UPIN number. Fill in patient details such as date of birth, height, weight, and sex.
5. Answer questions 1-6 regarding medical necessity by circling 'Y' for Yes or 'N' for No. Ensure that a qualified individual completes this section.
6. Section C requires a narrative description of equipment and costs from the supplier. Finally, Section D must be signed by the physician certifying all information is accurate.

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