DME MAC Jurisdiction C Suggested Intake Form at a glance
What it is: The DME MAC Jurisdiction C SUGGESTED INTAKE FORM: these are the basic questions to aid you in compiling information at the time of intake.
Who signs: Under SIGNATURE, the Beneficiary Signs and enters the Date Signed.
This is just a suggested intake form and suppliers can model one to fit their particular type of business.
A filled-in DME MAC Jurisdiction C Suggested Intake Form example: a replacement walker order
How to fill out DME MAC Jurisdiction C Suggested Intake Form, box by box
Order taken by and the referral person
Enter who the Order was taken by and the Date, then the Referral Person Calling in Order and the Telephone.
BENEFICIARY INFORMATION
Under BENEFICIARY INFORMATION, enter the Name and the Date of Birth.
Enter the Street Address and mark Male or Female under Sex.
Enter the City, State, Zip, Weight, Height, Telephone and Medicare #.
Name of Legally Responsible Representative
Enter the Name of Legally Responsible Representative, the Relationship to Beneficiary, the Street Address, the City, State, Zip and the Telephone.
ORDERING PHYSICIAN INFORMATION
Under ORDERING PHYSICIAN INFORMATION, enter the Name, NPI #, Street Address, Telephone and City, State, Zip.
Has the beneficiary ever received the same or similar supplies/equipment?
Under QUESTIONS FOR THE BENEFICIARY, mark Yes or No: Has the beneficiary ever received the same or similar supplies/equipment?
If yes, list equipment/supplies.
Enter Who was it purchased or rented from, the Date purchased, or if rented, how many months, the Date of past set-up, the Date equipment was returned and Why was the item returned to original supplier.
Is the item being replaced?
Mark Yes or No: Is the item being replaced? Is there a new medical necessity?
Describe condition for previous need and describe new/changed condition.
Medicare HMO/managed care program
Mark Yes or No: Is the beneficiary enrolled in a Medicare HMO/managed care program? Has the beneficiary been enrolled in a Medicare HMO/managed care program and is returning to Fee-For-Service (FFS)?
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 and Reason or nature of repairs.
For repairs, mark Yes or No: Do you have medical necessity to file for repairs? Does beneficiary meet criteria for item being repaired?
Questions for the Supplier, continued
Under Questions for the Supplier, continued, enter Where will the item be used.
SIGNATURE
Under SIGNATURE, the Beneficiary Signs and enters the Date Signed.
More rules for DME MAC Jurisdiction C Suggested Intake Form
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.
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.
Sources
[1] DME MAC Jurisdiction C Suggested Intake Form (Revised February 6, 2025), CGS Administrators, LLC (the Official source link on this page).