Form 4116 Dme PDF Details

In the realm of healthcare and medical equipment provision for individuals living with disabilities, the Form 4116-DME emerges as a pivotal document within Texas. Released in August 2007 by the Texas Department of Aging and Disability Services, this form plays an essential role in summarizing durable medical equipment (DME) services provided to clients residing in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). It meticulously records details such as the facility name, billing month, contract number, and client-specific information including their Medicaid number and the durable medical equipment required. Each entry captures the DME's year and the financial aspects, including the begin date, cost, and the total annual cost alongside year-to-date expenditures. Furthermore, it encompasses a checklist for providers, ensuring that bids and receipts are accounted for, alongside necessary contact information for effective communication. This comprehensive document ensures that the procurement and financing of essential medical equipment are conducted transparently and efficiently, highlighting its importance in the administration of care for those with disabilities.

QuestionAnswer
Form NameForm 4116 Dme
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswhat is form 4116 a, form 4116 a 2020, is 4116 a real tax form, form 4116

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Texas Department of Aging

Form 4116-DME

and Disability Services

August 2007-E

ICF/IID Durable Medical Equipment Summary Sheet

Facility Name

Billing Month

Contract Number

Client Name

Client

Medicaid No.

DME Year

DME Year

Begin Date

Cost

(MM/YYYY)

Year-to-Date

 

 

Date

Service

Received

Receipt

Date

DME Item/Service Description

Billing Dollars Total Annual

Cost

Code Spent Year-to-Date

DME

 

Checklist

Provider

MED

Bids

Receipt

EOB

No.

NEC

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person

Contact Person's Telephone No.

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