Form 847 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, select the appropriate certification type (Initial, Revised, or Recertification) and enter the required dates. Fill in the patient’s name, address, telephone number, and Medicare ID.
3. Provide your supplier information including name, address, telephone number, and either NSC or NPI number. Specify the place of service and supply item/service/procedure codes.
4. Complete Section B by entering the estimated length of need in months and listing diagnosis codes. Answer questions 1-11 as applicable by checking 'Y', 'N', or 'D'.
5. In Section C, provide a narrative description of all items ordered along with their costs. Ensure this section is completed by the supplier.
6. Finally, Section D requires the physician's signature and date to certify that all information is accurate and complete.

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