Dme information form 2025

1. Click ‘Get Form’ to open the DME Information Form in the editor.
2. Begin by filling out the Certification Type/Date section. Indicate whether this is an Initial, Revised, or Recertification by marking the appropriate box and entering the relevant dates.
3. In the Patient Information section, enter the patient's name, address, telephone number, and Health Insurance Claim Number (HICN) as it appears on their Medicare card.
4. Next, provide your Supplier Information including your company name, address, telephone number, and either your National Supplier Clearinghouse (NSC) number or National Provider Identifier (NPI).
5. Fill in the Place of Service field with the appropriate code indicating where the item will be used. If applicable, include the Facility Name and Address.
6. List all Supply Item/Service Procedure Codes that require certification in their designated section.
7. Complete the Patient's Date of Birth, Height, Weight, and Sex fields accurately.
8. Provide Physician Information including their name, address, telephone number, and UPIN or NPI.
9. Answer questions 1–4 regarding clinical information about the external infusion pump. Ensure you check 'Y' for yes or 'N' for no as required.
10. Finally, sign and date the Supplier Attestation to certify that all provided information is accurate before submitting your form.

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