Get Dme Information Form Cms-10126-enteral And Parenteral Nutrition

Filling out the DME Information Form CMS-10126 for Enteral and Parenteral Nutrition can seem complex, but this guide will help you navigate each section with ease. Follow the instructions carefully to ensure accurate completion of the form.

Follow the steps to complete the DME Information Form successfully.

1. Click ‘Get Form’ button to access the DME Information Form CMS-10126 and open it in your editable format.
2. Begin with the certification type and date section. Indicate whether this is an initial or revised certification by filling in the appropriate dates.
3. Provide the patient's name, address, telephone number, and Medicare ID as it appears on their Medicare card.
4. In the supplier information section, input the supplier's name, address, telephone number, and the appropriate Medicare Supplier Number or NPI.
5. Specify the place of service by indicating the relevant code, such as a home or skilled nursing facility.
6. If applicable, enter the name and address of the facility where the service will be provided.
7. List all supply item/service procedure codes for items requiring a DME Information Form.
8. Complete the patient's date of birth, height, weight, and sex as required.
9. Fill in the treating physician's name, address, and their UPIN or NPI number.
10. Answer each question in the question section based on the patient's clinical information, checking 'Y' for yes or 'N' for no as instructed.
11. Complete the supplier attestation by signing and dating the form to certify the information provided is accurate.
12. Once completed, you can save changes, download, print, or share the form as necessary.

Complete and submit your DME Information Form online today to ensure timely processing.