Form Cms-10125 - Dme Information - 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 HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
SUPPLY ITEM/SERVICE
PLACE OF SERVICE
PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
PROCEDURE CODE(S):
__________________________________________
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
if applicable (see reverse)
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
ANSWERS
ANSWER QUESTIONS 1–4 FOR EXTERNAL INFUSION PUMP.
SUPPLY ITEM/SERVICE PROCEDURE CODE(S):
1.
Provide the Supply Item/Service Procedure code(s) for the
drug(s) that requires the use of the pump.
a) _____________________________________________________________
b) _____________________________________________________________
c) _____________________________________________________________
2.
If a NOC (not otherwise classified) Supply Item/Service
a) _____________________________________________________________
Procedure code is listed in question 1, print name of drug.
b) _____________________________________________________________
c) _____________________________________________________________
3.
Check number for route of administration?
o 1
o 2
o 3
o 4
1 – Intravenous 2 – Subcutaneous 3 – Epidural 4 – Other
4.
Check number for method of administration?
o 1
o 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 _____/_____/_____
Signature and Date Stamps Are Not Acceptable.
Form CMS-10125 (03/14)

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