CERTIFICATION
TYPE/DATE:
PATIENT
INFORMATION:
SUPPLIER
INFORMATION:
PLACE OF SERVICE:
FACILITY NAME:
SUPPLY ITEM/SERVICE
PROCEDURE CODE(S):
If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in
the space marked “INITIAL.” If this is a revised certification (to be completed when the physician changes
the order, based on the patient’s changing clinical needs), indicate the initial date needed in the space
marked “INITIAL,” and also indicate the revision date in the space marked “REVISED.” If this is a
recertification, indicate the initial date needed in the space marked “INITIAL,” and also indicate the
recertification date in the space marked “RECERTIFICATION.” Whether submitting a REVISED or a
RECERTIFICATION DIF, be sure to always furnish the INITIAL date as well as the REVISED or
RECERTIFICATION date.
Indicate the patient’s name, permanent legal address, telephone number and his/her Medicare ID as it
appears on his/her Medicare card and on the claim form.
Indicate the name of your company (supplier name), address and telephone number along with the
Medicare Supplier Number assigned to you by the National Supplier Clearinghouse (NSC) or applicable
National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed
by the 10-digit number. If using a legacy number, e.g. NSC number, use the qualifier 1C followed by the
10-digit number. (For example. 1Cxxxxxxxxxx)
Indicate the place in which the item is being used, i.e., patient’s home is 12, skilled nursing facility (SNF)
is 31, End Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a
complete list.
If the place of service is a facility, indicate the name and complete address of the facility.
List all procedure codes for items ordered that require a DIF. Procedure codes that do not require
certification should not be listed in this section of the DIF.
PATIENT DOB, HEIGHT, Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in
WEIGHT AND SEX: pounds, if required.
PHYSICIAN NAME, Indicate the physician’s name and complete mailing address.
ADDRESS:
PHYSICIAN Accurately indicate the treating physician’s Unique Physician Identification Number (UPIN) or applicable
INFORMATION: National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed
by the 10-digit number. If using UPIN number, use the qualifier 1G followed by the 6-digit number.
(For example. 1Gxxxxxx)
PHYSICIAN’S Indicate the telephone number where the physician can be contacted (preferably where records would be
TELEPHONE NO.: accessible pertaining to this patient) if more information is needed.
QUESTION SECTION: This section is used to gather clinical information about the item or service billed. Answer each question
which applies to the items ordered, checking “Y” for yes, “N” for no, a number if this is offered as an answer
option, or fill in the blank if other information is requested.
SUPPLIER The supplier’s signature certifies that the information on the form is an accurate representation of the
ATTESTATION: situation(s) under which the item or service is billed.
SUPPLIER SIGNATURE After completion, supplier must sign and date the DME Information Form, verifying the Attestation.
AND DATE:
INSTRUCTIONS FOR COMPLETING DME INFORMATION FORM
FOR ENTERAL AND PARENTERAL NUTRITION (CMS-10126)
Form CMS-10126 (02/17) INSTRUCTIONS
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
this information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form,
please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.
DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.
