Cms 10126 2005 form-2025

1. Click ‘Get Form’ to open the CMS-10126 form in the editor.
2. Begin by filling out the Certification Type/Date section. Indicate whether this is an initial certification, revised, or recertification by marking the appropriate box and entering the relevant dates.
3. Next, provide the Patient Information. Enter the patient's name, address, telephone number, and Health Insurance Claim Number (HICN) as it appears on their Medicare card.
4. In the Supplier Information section, input your company’s 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 HCPCS codes for items ordered that require a DME Information Form in the designated section.
7. Complete patient details such as Date of Birth (DOB), height, weight, and sex.
8. Provide Physician Information including their name, address, telephone number, and UPIN or NPI number.
9. Answer all questions in the Question Section by circling 'Y' for Yes or 'N' for No as applicable.
10. Finally, ensure you sign and date the Supplier Attestation to certify that all information provided is accurate before submitting.

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