Get Cms-10125 2017-2025

The CMS-10125 form, also known as the DME Information Form for External Infusion Pumps, is essential for requesting durable medical equipment. This guide will provide you with clear, step-by-step instructions on filling out the form online effectively.

Follow the steps to complete the CMS-10125 online.

1. Click the ‘Get Form’ button to access the CMS-10125 form and open it in your preferred online editor.
2. In the certification type/date section, select whether this is an initial, revised, or recertification request by writing the applicable dates in the designated fields.
3. Fill in the patient information by entering the patient's full name, permanent address, telephone number, and Medicare ID as shown on their Medicare card.
4. Provide the supplier information, which includes the name of your company, your address, phone number, and your National Supplier Clearinghouse (NSC) or National Provider Identifier (NPI) number.
5. Indicate the place of service using the appropriate code for where the equipment will be used—e.g., home, skilled nursing facility, etc.
6. If applicable, enter the name and address of the facility where the patient is receiving treatment.
7. List the supply item/service procedure codes for the items being ordered that require this form. Ensure to include only codes that necessitate certification.
8. Enter the patient's date of birth, sex, height in inches, and weight in pounds in the respective fields.
9. Fill in the physician's information including their name, address, phone number, and either UPIN or NPI.
10. Answer the questions in the question section by responding appropriately and providing details where necessary, marking 'Y' for yes, 'N' for no, or other required information.
11. In the supplier attestation section, acknowledge that the information provided is accurate by signing and dating the form.
12. Once completed, make sure to save the changes made to the document, and you may download, print, or share the CMS-10125 form as needed.

Start filling out your CMS-10125 form online today to ensure timely and accurate processing.