Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. In the first section, enter the patient’s name by filling in their last name, first name, and middle initial.
3. Next, provide the patient’s date of birth in the specified format: month, day, and year.
4. Enter the subscriber’s certificate number. Ensure to include the alpha prefix as found on your identification card.
5. Indicate the patient's relationship to the subscriber by selecting from the options provided: self, spouse, child, or dependent.
6. Complete the patient’s sex by checking either male or female.
7. If applicable, answer whether the condition was related to the patient’s employment or an accident.
8. Provide the date when the accident or injury occurred, using the correct format.
9. Include the subscriber’s address along with the city, state, and ZIP code. Check 'New Address' if this is different from prior submissions.
10. Indicate whether the patient is covered under any other health insurance policy, and if yes, provide the name of the company and identification number.
11. Fill out the provider information section, giving details about where the hardware was purchased, including the company name and identification number.
12. Document any illnesses or injuries for which the patient was treated, ensuring to include the diagnosis code.
13. Indicate the date of purchase of the hardware, followed by the total charges for the items provided.
14. Complete the last section by signing the form and entering the date it was completed.
15. Once all fields are filled out correctly, save any changes made, and proceed to download, print, or share the form as necessary.

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