Dme 0903 printable form 2005-2026

1. Click ‘Get Form’ to open the DME 0903 printable form in the editor.
2. Begin by filling out the Certification Type/Date section. Indicate whether this is an initial, revised, or recertification request by entering the appropriate dates.
3. In the Patient Information section, enter the patient's name, address, telephone number, and HIC number as it appears on their Medicare card.
4. Complete the Supplier Information section with your company name, address, telephone number, and either your NSC or NPI number.
5. Specify the Place of Service using the appropriate code for where the item will be used.
6. List all relevant HCPCS codes for items ordered that require a DME Information Form in the designated area.
7. Fill in patient details such as date of birth, height, weight, and sex in the Patient DOB section.
8. Provide physician information including their name, address, telephone number, and applicable NPI or UPIN number.
9. Answer questions regarding external infusion pumps by circling numbers or filling in blanks as required.
10. Finally, sign and date the Supplier Attestation to certify that all information provided is accurate before submitting your form.

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