Get Dme Information Form

Filling out the Dme Information Form online can simplify the process of providing essential health information. This guide will walk you through each step to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the Dme Information Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the certification type and date. Indicate whether this is an initial, revised, or recertification entry by selecting the appropriate box and filling in the date.
3. Fill in the patient information section by entering the patient's name, address, telephone number, and Health Insurance Claim (HIC) number.
4. Next, provide supplier details by entering the supplier’s name, address, telephone number, and National Supplier Clearinghouse (NSC) or National Provider Identifier (NPI) number.
5. Specify the place of service and enter the name and address of the facility if applicable.
6. Complete the HCPCS code section by noting the relevant codes for the products used.
7. Enter the patient’s date of birth, sex, height, and weight in the designated fields.
8. Provide the physician's information, including their name, address, telephone number, and NPI or Unique Physician Identification Number (UPIN).
9. Indicate the estimated length of need in months, specifying a number between 1 and 99 (with 99 representing lifetime).
10. Fill in the diagnosis codes (ICD-9) related to the patient.
11. Answer questions 1 to 6 pertaining to enteral nutrition by circling 'Y' for yes or 'N' for no, and provide additional information as needed.
12. For questions regarding parenteral nutrition, answer questions 6 to 9 accordingly and provide the requested details.
13. Complete the supplier attestation section by signing and dating the form, ensuring that the signature is handwritten as stamps are not acceptable.
14. Once all fields are completed, save your changes, and you may choose to download, print, or share the form as necessary.

Take the next step by completing the Dme Information Form online today!