Dme Certification And Receipt Form Page 3
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4DME Certification and Receipt Form
Certificación y Recibo de Equipo Medico Duradero (DME)
(Page 3 of 4—Required only for requests containing six or more items)
Client Information
Medicaid ID Number:
Provider Information
Provider Name:
Prior Authorization Number (PAN):
NPI/API:
TPI:
Product Information (Continuation)
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.:
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.:
Procedure Code:
Description:
Serial No.:
Procedure Code:
Description:
Serial No.:
Procedure Code:
Description:
Serial No.:
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
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
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