Dme Certification And Receipt Form
Download a blank fillable Dme Certification And Receipt Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dme Certification And Receipt Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4DME Certification and Receipt Form
Certificación y Recibo de Equipo Medico Duradero (DME)
(Page 1 of 4—Required)
This certification is required by section 32.024 of the Human Resources Code and must be completed before the DME provider can be paid for
durable medical equipment provided to a Medicaid client.
Esta certificación es necesaria bajo la Sección 32.024 del Código de Recursos Humanos y se debe Ilenar antes de poder rembolsar al proveedor
del equipo médico duradero por cualquier equipo médico proporcionado al cliente de Medicaid.
Section A: Client Information
Name:
Medicaid ID Number:
Address:
City
State
ZIP:
Telephone Number:
Alternate Telephone Number:
Section B: Provider Information
Provider Name:
Prior Authorization Number (PAN)
NPI/API:
TPI:
Section C: Product Information
Date of Service:
Procedure Code:
Description:
Serial No:
Procedure Code:
Description:
Serial No:
Procedure Code:
Description:
Serial No:
Procedure Code:
Description:
Serial No:
Procedure Code:
Description:
Serial No:
Section D: Certification
This is to certify that on (month/day/year) _________________________ the client received the ______________________________________
(equipment) as prescribed by the physician. The equipment has been properly fitted to the client and/or meets the client’s needs.
The client, parent, or the guardian of the client, and/or caregiver of the client has received training and instruction regarding the equipment’s
proper use and maintenance.
________________________________________
___________________________________________________
Printed name of DME Supplier
Printed name of Client, Parent, Guardian, or Primary Caregiver
________________________________________
___________________________________________________
Signature of DME Supplier
Signature of Client, Parent, Guardian, or Primary Caregiver
Section D (Optional) : Certification (Spanish)
Esto certifica que el: (mes/día/año) ______________________________ el cliente recibió [el] [la] [los] [las]
_____________________________________ (equipo) que el doctor recetó. El equipo ha sido adaptado correctamente para el cliente o
satisface las necesidades del cliente.
El cliente, padre, o tutor, o el cuidador principal del cliente ha recibido entrenamiento e instrucción con respecto al uso y mantenimiento
apropiado del equipo.
________________________________________
___________________________________________________
Nombre del Proveedor del Equipo Medico Duradero
Nombre del Cliente, Padre, Tutor, o Cuidador Principal
________________________________________
___________________________________________________
Firma del Proveedor del Equipo Medico Duradero
Firma del Cliente, Padre, Tutor, o Cuidador Principal
F00018
Effective Date_07/01/2011/Revised Date_10/06/2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Calyx Form Bsa.hp - Borrower Signature Authorization, Borrowers' Certification And Authorization, Form 4506-t - Request For Transcript Of Tax Return
Financial
Form 6a - Release And Receipt Of Imported Firearms, Ammunition And Implements Of War (atf Form 5330.3c) Instructions
Legal
Related Categories
Parent category: Business