Get Dma 5164

Filling out the Dma 5164 form is an important step in managing claims related to the PML (Personal Monthly Liability). This guide will provide you with a comprehensive overview and clear instructions for successfully completing the form online.

Follow the steps to accurately complete the Dma 5164 form.

1. Click the ‘Get Form’ button to access the Dma 5164 and open it in the editor.
2. Enter your details in the 'FROM' field, including your name and the IMC (Intermediary Medicare Contractor) designation.
3. Provide your contact number in the designated field to ensure communication regarding your request.
4. Complete the 'DATE' section to indicate when the form is being filled out.
5. In the 'RE' section, enter the beneficiary's name associated with the PML request.
6. Fill in the 'MID#' field, ensuring you provide the correct identification number for the beneficiary.
7. Specify the 'FROM AND THRU DATES FOR PML CORRECTION' to indicate the timeframe relevant to the PML adjustment.
8. Indicate the 'PML AMOUNT NEEDED' to specify the adjustment amount.
9. In the 'INCORRECT PML IN NCFAST' section, enter the previously recorded incorrect PML amount.
10. Select an appropriate reason for changing the PML under PART I by marking the corresponding checkbox.
11. If necessary, provide detailed explanations for changes required in PART II, describing the reasons for the adjustment clearly.
12. Review all sections for accuracy before finalizing your form.
13. Once the form is filled out correctly, opt to save changes, download, print, or share the completed Dma 5164 form.

Start filling out your Dma 5164 form online today to streamline your claims process.