Get Dme Certification And Receipt Form - Tmhp.com

Filling out the DME Certification And Receipt Form is essential for durable medical equipment providers to receive payment for services rendered to Medicaid clients. This guide provides detailed, step-by-step instructions on how to complete the form online, ensuring accuracy and compliance.

Follow the steps to complete the DME Certification And Receipt Form successfully.

1. Click the ‘Get Form’ button to access the DME Certification And Receipt Form and open it in your preferred editing tool.
2. In Section A, provide the client information. Fill in the client's name, address, telephone number, Medicaid ID number, city, state, and any alternate telephone number if available.
3. Proceed to Section B and enter the provider information. This includes the provider's name, NPI/API number, prior authorization number, and TPI.
4. In Section C, detail the product information. Enter the date of service, relevant procedure codes, descriptions of the durable medical equipment, and serial numbers.
5. In Section D, provide certification details. Fill in the date the client received the equipment and the description of the equipment. Ensure the printed names and signatures of the DME supplier and the client or their representative are included.
6. If applicable, complete Section E for Qualified Rehabilitation Professional verification for wheeled mobility systems. Fill in the required dates, signatures, and printed names.
7. Once you have completed all necessary sections, ensure that all information is accurate and complete. Save your changes, and you may opt to download, print, or share the completed form as needed.

Complete your DME Certification And Receipt Form online today to ensure timely processing and payment.