Form Cms-10125 Dme Information Form Cms-10125 - External Infusion Pumps

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
DME INFORMATION FORM
DME 09.03
CMS-10125 — EXTERNAL INFUSION PUMPS
Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE______________
HCPCS CODE
PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable
if applicable (see reverse)
NPI NUMBER or UPIN
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
ANSWERS
ANSWER QUESTIONS 1 - 4 FOR EXTERNAL INFUSION PUMP.
HCPCS CODE:
1. Provide the HCPCS code(s) for the drug(s) that requires the use
of the pump.
a) _______________________________________________________
b) _______________________________________________________
c) _______________________________________________________
2. If a NOC (not otherwise classified) HCPCS code is listed in
a) _______________________________________________________
question 1, print name of drug.
b) _______________________________________________________
c) _______________________________________________________
3. Circle number for route of administration?
1
2
3
4
1 — Intravenous 2 — Subcutaneous 3 — Epidural 4 — Other
4. Circle number for method of administration?
1
2
1 – Continuous
2 – Intermittent
Supplier Attestation and Signature/Date
I certify that I am the supplier identified on this DME Information Form and that the information provided is true, accurate, and complete, to the best
of my knowledge. I understand that any falsification, omission, or concealment of material fact associated with billing this service may subject me to
civil or criminal liability.
SUPPLIER SIGNATURE_________________________________________________________________________ DATE _____/_____/_____
Form CMS-10125 (09/05) EF 08/2006

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