Form Cms-10126 - Dme Information Form - Enteral And Parenteral Nutrition
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
DME INFORMATION FORM
DME 10.03
CMS-10126 — ENTERAL AND PARENTERAL NUTRITION
All INFORMATION ON THIS FORM MAY BE COMPLETED BY THE SUPPLIER
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
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
Supply Item/Service
PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
PLACE OF SERVICE__________________________
Procedure Code(s):
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
if applicable (see reverse)
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
EST. LENGTH OF NEED (# OF MONTHS): ______ 1–99 (99=LIFETIME)
DIAGNOSIS CODES: ______ ______ ______ ______
ANSWER QUESTIONS 1–6 FOR ENTERAL NUTRITION, AND 6–9 FOR PARENTERAL NUTRITION
ANSWERS
(Check Y for Yes, N for No, Unless Otherwise Noted)
1.
Is there documentation in the medical record that supports the patient having a permanent non-function or
o Y
o N
disease of the structures that normally permit food to reach or be absorbed from the small bowel?
2.
Is the enteral nutrition being provided for administration via tube? (i.e., gastrostomy tube, jejunostomy tube,
o Y
o N
nasogastric tube)
3.
Print Supply Item/Service Procedure Code(s) of product.
A)________________
B)________________
4.
Calories per day for each corresponding Supply Item/Service Procedure Code(s).
A)________________
B)________________
5.
Check the number for method of administration?
o 1 o 2 o 3 o 4
1 – Syringe
2 – Gravity
3 – Pump
4 – Oral (i.e. drinking)
_______
6.
Days per week administered or infused (Enter 1–7)
7.
Is there documentation in the medical record that supports the patient having permanent disease of the
o Y
o N
gastrointestinal tract causing malabsorption severe enough to prevent maintenance of weight and strength
commensurate with the patient’s overall health status?
8.
Formula components:
Amino Acid ___________ (ml/day) _______________concentration % ______ gms protein/day
Dextrose ______________ (ml/day) _______________concentration %
Lipids _________________ (ml/day) _______________days/week ____________ concentration %
9.
Check the number for the route of administration.
o 1 o 2 o 3
1 – Central Line (Including PICC)
2 – Hemodialysis Access Line
3 – Peritoneal Catheter
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-10126 (03/14)
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