Get Cms-10125 2014

The CMS-10125 is a vital form used for the documentation of durable medical equipment related to external infusion pumps. This guide provides detailed, step-by-step assistance in filling out the form online, ensuring that users can complete it accurately and efficiently.

Follow the steps to fill out the CMS-10125 form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating the certification type and date. Choose either 'initial,' 'revised,' or 'recertification,' and fill in the necessary dates in the respective fields.
3. Enter the patient information, including their full name, permanent address, telephone number, and health insurance claim number (HICN) from their Medicare card.
4. Provide your supplier information by filling in your company's name, address, telephone number, and either the National Supplier Clearinghouse (NSC) number or the National Provider Identifier (NPI) number, ensuring to use the appropriate qualifier.
5. Specify the place of service where the item will be used by entering the corresponding code (e.g., '12' for patient’s home). Refer to relevant guidelines for the complete list of codes.
6. If applicable, enter the name and address of the facility where the service will be provided.
7. List all HCPCS procedure codes for the items ordered that require this form, ensuring not to include codes that do not require certification.
8. Input the patient's date of birth, sex, height in inches, and weight in pounds.
9. Fill in the physician’s name and complete mailing address, along with their Unique Physician Identification Number (UPIN) or NPI number.
10. Provide the physician's telephone number where they can be contacted for further information.
11. Answer the clinical information questions applicable to the items ordered. Indicate 'Y' for yes, 'N' for no, or fill in any required information.
12. Complete the supplier attestation section by signing and dating the form, certifying the accuracy of the information provided.
13. Once all fields are complete, you can choose to save changes, download, print, or share the filled-out form.

Take action now by completing the CMS-10125 online.