Get Aplication And Checklist For Pdac Hcpcs Coding Durable Medical Equipment And Supplies Form

This guide provides comprehensive instructions for filling out the Application and Checklist for PDAC HCPCS Coding Verification Request Form online. Following these steps will ensure that your application is complete and submitted successfully.

Follow the steps to complete the application effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section A, which requires submitter identification. Indicate whether the application is submitted by a consultant, manufacturer, or distributor. Fill out the name of the corporation or organization, the contact person's name, email address, phone number, and mailing address.
3. Move to Section B, which contains marketing information. Provide FDA information as applicable and indicate the expected date of market entry if the product is not yet available. List the appropriate HCPCS codes and confirm whether the product will be used by a patient in a home setting.
4. Proceed to Section C, where you must detail product specifications. List all components and accessories, type of wheelchair cushion, describe the fabrication process, materials used, functions, and indications for use. Include proof of fire retardant properties according to California Bulletin 117 or 133.
5. Continue to Section D, which requires product listings on the Durable Medical Equipment Coding System. Fill in all model numbers and ensure that the base HCPCS code and any add-on codes are listed appropriately.
6. Complete Section E by providing the necessary authorization signatures. Ensure that the Authorized Official Name, Company Name, Title, Original Signature, and Date are included. Note that a second signature is required for distributor applications.
7. Review the checklist provided at the end of the form to ensure all sections are complete. Compile any necessary miscellaneous documentation, such as pictures of the item, current marketing literature, engineering drawings, and samples if applicable.
8. Once all sections are filled out correctly, you can save changes, download, print, or share the completed form as necessary.

Complete your application online to ensure proper coding verification for your durable medical equipment and supplies.