Get Dmerc 02 03a Form

Filling out the Dmerc 02 03a Form is an essential process for individuals requiring medical equipment such as motorized wheelchairs. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently online.

Follow the steps to complete the Dmerc 02 03a Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your browser.
2. Begin with Section A, where you will enter the certification type and date, along with the patient's name, address, telephone number, and Health Insurance Claim (HIC) number. Ensure that all information is accurate.
3. Continue filling in the supplier's details in Section A, including their name, address, telephone number, and National Supplier Clearinghouse (NSC) number.
4. Provide the place of service and the facility's name and address, if applicable. Then, fill in the necessary HCPCS codes and patient details, including date of birth, sex, height, and weight.
5. Move to Section B, where you will complete the UPIN information. Note that this section cannot be filled out by the supplier.
6. Specify the estimated length of need for the equipment in months, selecting a range from 1 to 99.
7. Fill out the diagnosis codes in Section B, which are important for justifying the medical necessity of the wheelchair.
8. Answer the questions related to the motorized wheelchair and its accessories, circling 'Y' for yes, 'N' for no, or 'D' for does not apply as needed.
9. In Section C, provide a narrative description of the equipment, including details on items and costs. This section requires listing quantities, manufacturers, model numbers, descriptions, codes, and pricing.
10. Finally, complete Section D with the physician’s attestation, including their signature and date, ensuring that all the information provided is true and accurate.
11. After all sections are completed, review the form for any errors or omissions, and then proceed to save, download, print, or share the completed form as needed.

Start filling out your Dmerc 02 03a Form online today for a smooth process.