Form Cms 10125 – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved OMB

No. 0938-0679

CENTERS FOR MEDICARE & MEDICAID SERVICES

Expires 02/2024

PATIENT NAME, ADDRESS, TELEPHONE and Medicare ID

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #

(__ __ __) __ __ __ - __ __ __ __ Medicare ID _______________________

(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________

PLACE OF SERVICE

SUPPLY ITEM/SERVICE

PT DOB ____/____/____ Sex ____ (M/F)

Ht. ____(in) Wt ____(lbs.)

PROCEDURE CODE(S):

__________________________________________

NAME and ADDRESS of FACILITY

__________

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #

if applicable (see reverse)

__________

__________

__________

(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________

ANSWERS

ANSWER QUESTIONS 1–4 FOR EXTERNAL INFUSION PUMP.

SUPPLY ITEM/SERVICE PROCEDURE CODE(S):

1. Provide the Supply Item/Service Procedure code(s) for the

drug(s) that requires the use of the pump.

a) _____________________________________________________________

b)_____________________________________________________________

c) _____________________________________________________________

a) _____________________________________________________________

2.

If a NOC (not otherwise classified) Supply Item/Service

Procedure code is listed in question 1, print name of drug.

b)_____________________________________________________________

c) _____________________________________________________________

o 1

o 2

o 3

o 4

3. Check number for route of administration?

1 – Intravenous

2 – Subcutaneous

3 – Epidural 4 – Other

o 1

o 2

4.

Check number for method of administration?

1 – Continuous

2 – Intermittent

CERTIFICATION

If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed

TYPE/DATE:

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.

PATIENT

Indicate the patient’s name, permanent legal address, telephone number and his/her Medicare ID

INFORMATION:

as it appears on his/her Medicare card and on the claim form.

SUPPLIER

Indicate the name of your company (supplier name), address and telephone number along with

INFORMATION:

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)

PLACE OF SERVICE:

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.

FACILITY NAME:

If the place of service is a facility, indicate the name and complete address of the facility.

PATIENT DOB,

Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches

HEIGHT, WEIGHT

and weight in pounds, if required.

AND SEX:

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

INFORMATION:

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 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

TELEPHONE NO:

would be 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

ATTESTATION:

of the situation(s) under which the item or service is billed.

SUPPLIER

After completion, supplier must sign and date the DME Information Form,

SIGNATURE

verifying the Attestation.

AND DATE: