Get Portable Oxygen Concentrator - Hmi Medical

Filling out the Portable Oxygen Concentrator form accurately is crucial for ensuring the proper medical equipment is provided. This guide offers comprehensive step-by-step instructions to successfully complete the form online, catering to both new and experienced users.

Follow the steps to complete the Portable Oxygen Concentrator form online.

1. Press the ‘Get Form’ button to access the Portable Oxygen Concentrator - HMI Medical form and open it in your designated digital workspace.
2. In Section A, provide the Certification Type and Date. Indicate whether this is an Initial, Revised, or Recertification by marking the appropriate box and filling in the corresponding dates.
3. Fill in the Patient Name, Address, Telephone number, and HIC Number as they appear on the patient's Medicare card.
4. Enter the Supplier Name, Address, Telephone, and either the NSC Number or NPI Number assigned to your business.
5. Indicate the Place of Service using the corresponding code for the location where the oxygen is being utilized.
6. In Section B, provide the Patient's Date of Birth, Sex, and HCPCS Codes relevant to the prescribed items.
7. Enter the physician’s information including Name, Address, Telephone number, and applicable NPI or UPIN Number.
8. Complete the estimated length of need and enter the Diagnosis Codes that justify the medical necessity for the portable oxygen concentrator.
9. Answer questions 1-9 in the questionnaire to provide clinical data related to the oxygen therapy required for this patient.
10. In Section C, describe all ordered items and their associated costs. Include the Supplier's Charge and Medicare Fee Schedule Allowance for each item listed.
11. Finally, in Section D, the physician must sign and date the attestation, confirming the information provided is accurate and complete.
12. Make sure to review all your entries, then save your changes. You can download, print, or share the completed form as needed.

Complete the Portable Oxygen Concentrator - HMI Medical form online today to ensure timely access to essential medical equipment.