Form 4116 Dme – Fill Out and Use This PDF

Updated: Nov 2, 2026

The 4116-DME Form serves as a durable medical equipment summary sheet used by the Texas Department of Aging and Disability Services. It is an essential document that captures detailed information about the durable medical equipment provided to clients, including the billing month, service dates, item descriptions, costs, and provider details. To ensure the provision of necessary equipment to those in need, the accurate completion of this form is crucial.

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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.

Question	Answer
Form Name	Form 4116 Dme
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	what is form 4116 a, form 4116 a 2020, is 4116 a real tax form, form 4116

How to Fill Out Form 4116-DME

Form 4116-DME at a glance

What it is: Form 4116-DME is the ICF/IID Durable Medical Equipment Summary Sheet of the Texas Department of Aging and Disability Services.

A filled-in Form 4116-DME example: a facility reports one client's equipment

Form 4116-DME example filled out, example: a facility reports one client's equipment — Sample Care Facility fills out Form 4116-DME for one client. One item is billed for March 2026 and no papers are attached yet, so Checklist stays empty. The picture shows only the first line, and all its values are invented. The year begins 09/2025. The item is the only one billed this year, so its dollars spent equal the total annual cost year-to-date. Sam Sample is the contact person.

How to fill out Form 4116-DME, box by box

Facility Name, Billing Month and Contract Number

Enter the Facility Name, the Billing Month and the Contract Number.

Client Name and Client Medicaid No.

Enter the Client Name and the Client Medicaid No.

DME Year Begin Date and DME Year Cost Year-to-Date

Enter the DME Year Begin Date (MM/YYYY) and the DME Year Cost Year-to-Date.

Date Service Received, Receipt Date, DME Item/Service Description and Billing Code

Enter the Date Service Received, the Receipt Date, the DME Item/Service Description and the Billing Code.

Dollars Spent and Total Annual Cost Year-to-Date

Enter the Dollars Spent and the Total Annual Cost Year-to-Date.

DME Provider No.

Enter the DME Provider No.

Checklist

The Checklist lists MED NEC, Bids, Receipt and EOB.

Contact Person

Enter the Contact Person and the Contact Person's Telephone No.

Sources

[1] Form 4116-DME, ICF/IID Durable Medical Equipment Summary Sheet, Texas Department of Aging and Disability Services (the Official source link on this page).