Dme Intake Form PDF Details

Navigating the healthcare system can be a complex process, especially when it involves obtaining durable medical equipment (DME). To streamline this process, the DME MAC Jurisdiction C Suggested Intake Form plays a crucial role. This comprehensive form, designed to be filled out when placing an order, captures essential information from both the beneficiary and the supplier. Its purpose extends beyond mere formality; it ensures that every piece of required data, including beneficiary’s personal and medical information, is efficiently gathered at the outset. Details such as the beneficiary's name, Medicare number, and specific needs regarding their equipment or supplies are systematically recorded. Moreover, it delves into the history of the beneficiary's equipment usage, questioning whether there have been previous rentals or purchases of similar items. This information is vital to determine medical necessity and to prevent redundant equipment provision. The form also prompts for details about the ordering physician, which facilitates verification and authorization of the equipment request. On the supplier side, questions are designed to gather specifics about the equipment being provided or repaired, ensuring that the services rendered align with the beneficiary's current medical requirements. Using this suggested form as a model, suppliers can tailor the document to fit the specific needs of their operations, whether they specialize in oxygen tanks, wheelchairs, or other forms of DME. This adaptability underscores the form's value as an integral part of the DME provision process, aiding in the seamless delivery of necessary equipment to those in need.

QuestionAnswer
Form NameDme Intake Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedicare intake form, medicare intake, sample medical intake form dme, dme intake process

Form Preview Example

DME MAC JURISDICTION C SUGGESTED INTAKE FORM

Order taken by:

Date:

 

 

Referral Person Calling in Order:

Telephone:

 

 

BENEFICIARY INFORMATION

Name:

 

Date of Birth:

 

 

 

 

 

 

 

Street Address:

 

Gender:

Male

Female

 

 

 

 

 

City, State, Zip:

 

Weight:

 

Height:

 

 

 

 

 

Telephone:

 

Medicare #:

 

 

 

 

 

 

 

Name of Legally Responsible Representative:

 

 

 

 

 

 

 

 

 

Relationship to Beneficiary:

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

City, State, Zip:

 

Telephone:

 

 

 

 

 

 

 

ORDERING PHYSICIAN INFORMATION

 

 

 

 

Name:

 

NPI #:

 

 

 

 

 

 

 

Street Address:

 

Telephone:

 

 

 

 

 

 

 

City, State, Zip:

 

 

 

 

 

 

 

 

 

QUESTIONS FOR THE BENEFICIARY

 

 

 

 

Has the beneficiary ever received the same or similar supplies/equipment?

 

 

Yes

No

 

 

 

 

 

If yes, list equipment/supplies:

 

 

 

 

 

 

 

 

 

Who was it purchased or rented from?

 

 

 

 

 

 

 

 

 

 

 

Date equipment

Date purchased, or if rented, how many months?

Date of past set-up:

 

was returned:

 

 

 

 

 

Why was the item returned to original supplier?

 

 

 

 

 

 

 

 

 

Is the item being replaced?

 

 

Yes

No

 

 

 

 

 

Is there a new medical necessity?

 

 

Yes

No

 

 

 

 

 

Describe condition for previous need:

 

 

 

 

 

 

 

 

 

Describe new/changed condition:

 

 

 

 

 

 

 

 

 

Is the beneficiary enrolled in a Medicare HMO/managed care program?

 

 

Yes

No

 

 

 

 

 

Has the beneficiary been enrolled in a Medicare HMO/managed care

 

 

Yes

No

program and is returning to Fee-For-Service (FFS)?

 

 

 

 

 

 

 

Page 1 of 2

Revised February 11, 2014.

© 2014 Copyright, CGS Administrators, LLC.

DME MAC JURISDICTION C SUGGESTED INTAKE FORM

QUESTIONS FOR THE SUPPLIER

(If providing repairs on equipment, obtain the following information for the item being repaired)

Manufacturer:

Model Name or #:

Serial #:

Purchase Date:

 

 

 

 

 

Reason or nature of repairs:

 

 

 

 

 

 

 

 

Do you have medical necessity to file for repairs?

 

Yes

No

 

 

 

 

Does beneficiary meet criteria for item being repaired?

 

Yes

No

 

 

 

 

 

Questions for the Supplier, continued . .

.

 

 

 

 

 

 

 

 

Where will the item be used?

 

 

 

 

 

 

 

 

 

SIGNATURE

Beneficiary Signature:

Date Signed:

 

 

This is just a suggested intake form and suppliers can model one to fit their particular type of business. For example, if you are providing oxygen, there may be certain questions you need to ask regarding oxygen patients, or, if you are providing wheelchairs, there may be certain questions pertinent to wheelchairs. These are the basic questions to aid you in compiling information at the time of intake. This form does not in any way replace obtaining an Advance Beneficiary Notice (ABN), if there is reason to believe the item(s) may be denied due to medical necessity reasons. Please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 3, for information about same/similar equipment and ABNs and the Limitation of Liability section in Chapter 6, for more information.

Page 2 of 2

Revised February 11, 2014.

© 2014 Copyright, CGS Administrators, LLC.

How to Edit Dme Intake Form Online for Free

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Concentrate while filling out this document. Ensure each and every blank is filled out correctly.

1. For starters, while filling out the medicare intake, start out with the form section that contains the following blank fields:

Step number 1 of submitting dme intake document samples

2. The subsequent part is to complete the next few blank fields: City State Zip, QUESTIONS FOR THE BENEFICIARY, Has the beneficiary ever received, If yes list equipmentsupplies, Who was it purchased or rented from, Date purchased or if rented how, Date of past setup, Why was the item returned to, Is the item being replaced, Is there a new medical necessity, Describe condition for previous, Describe newchanged condition, Yes No, Date equipment was returned, and Yes No.

dme intake document samples conclusion process explained (portion 2)

3. Within this step, look at Is the beneficiary enrolled in a, Has the beneficiary been enrolled, Yes No, Yes No, Page of, Revised February, and Copyright CGS Administrators LLC. Each of these are required to be completed with utmost attention to detail.

dme intake document samples writing process described (part 3)

4. This particular paragraph arrives with these blanks to fill out: QUESTIONS FOR THE SUPPLIER If, Manufacturer, Model Name or, Serial, Purchase Date, Reason or nature of repairs, Do you have medical necessity to, Does beneficiary meet criteria for, Questions for the Supplier, Where will the item be used, SIGNATURE, Beneficiary Signature, Yes No, Yes No, and Date Signed.

Part no. 4 for filling in dme intake document samples

In terms of Do you have medical necessity to and Purchase Date, make sure that you do everything right here. Both of these are definitely the key ones in the file.

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