Get Cms Form 382 - Esrd Network #15

Filling out the CMS Form 382 - ESRD Network #15 online is an essential process for Medicare beneficiaries undergoing home dialysis. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the CMS Form 382 online.

1. Click ‘Get Form’ button to access the CMS Form 382 - ESRD Network #15 and open it in your editor.
2. In section 1, enter your name as it appears on your Medicare card, using your last name, first name, and middle initial.
3. In section 2, provide your health insurance claim number, which is also your Medicare claim number.
4. For section 3, input your date of birth in the specified format (month/day/year).
5. In section 4, select your sex by checking either the ‘Male’ or ‘Female’ box.
6. For section 5, enter the provider number of the facility where you will receive home dialysis training.
7. In section 5A, provide the name and address of the facility providing your home dialysis training.
8. Fill section 6 with the provider number of the facility that will provide your home dialysis support services.
9. In section 6A, enter the name and address of the dialysis facility that will offer your support services.
10. For section 7, indicate whether you are making an initial selection, cancellation, or a routine selection change.
11. In section 8, check the box corresponding to the type of dialysis you will receive: Hemodialysis, CAPD, or CCPD.
12. Complete section 9 by providing the date when your home dialysis training is completed.
13. In section 10, check either Method I or Method II as per your preference for receiving dialysis supplies and services.
14. If you selected Method II, fill in section 11 with the name and address of the durable medical equipment supplier.
15. In section 12, by signing, certify that you have only one Method II supplier and understand the payment implications.
16. Check the location in section 13, indicating where your home dialysis will be provided.
17. Sign the form in section 14 to confirm your understanding and agreement with the selections made.
18. In section 15, enter the date you are signing the form, followed by the effective date of any method exception in section 16.
19. Once completed, ensure all sections of the form are filled, save your changes, and download or print a copy for your records.
20. Submit the form as required, ensuring to follow any further instructions indicated for submission.

Complete your CMS Form 382 online today to ensure you receive the home dialysis service you need.