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DME Certification and Receipt Form
Certificación y Recibo de Equipo Médico Duradero (DME)
(Page 1 of 3—Required)
This certification is required by section 32.024 of the Human Resources Code and must be completed before the DME provider can be paid for durable medical equipment provided to a Medicaid client. Esta certificación es necesaria bajo la Sección 32.024 del Código de Recursos Humanos yse debe llenar antes de pagarle al proveedor de equipo médico duradero por el equipo entregado al cliente de Medicaid.

Section A: Client Information Name: Address: Telephone Number: Section B: Provider Information Provider Name: NPI/API: Section C: Product Information Date of Service: Procedure Code: Procedure Code: Procedure Code: Procedure Code: Procedure Code: Section D: CertificationDescription: Description: Description: Description: Description:

Medicaid ID Number: City: State: Alternate Telephone Number:

ZIP:

Prior Authorization Number (PAN): TPI:

Serial No.: Serial No.: Serial No.: Serial No.: Serial No.:

This is to certify that on (month/day/year) _______________________ the client received the __________________________ (equipment) as prescribed by thephysician. The equipment has been properly fitted to the client and/or meets the client’s needs. The client, parent, guardian of the client, and/or caregiver of the client has received training and instruction regarding the equipment’s proper use and maintenance. ________________________________________ Printed name of DME Supplier ___________________________________________________ Printed name ofClient, Parent, Guardian, or Primary Caregiver

________________________________________ Signature of DME Supplier

___________________________________________________ Signature of Client, Parent, Guardian, or Primary Caregiver

Section D (Optional) : Certification (Spanish)
Esto certifica que el: (mes/día/año) _________________________ el cliente recibió _____________________________ (equipo)que el doctor recetó. El equipo fue adaptado correctamente para el cliente y satisface sus necesidades. El cliente, padre, tutor o cuidador principal del cliente recibió entrenamiento e instrucción en el uso y mantenimiento correcto del equipo. ________________________________________ Nombre del proveedor de equipo médico duradero ________________________________________ Firma del proveedor deequipo médico duradero ___________________________________________________ Nombre del cliente, padre, tutor o cuidador principal ___________________________________________________ Firma del cliente, padre, tutor o cuidador principal

This form must be submitted to TMHP for DME products with an allowed amount of $2500 dollars or more. Submit this form with claim form or fax this form to 512-506-6615.Information submitted in this form must match the claim form. This form must be filled out completely; place none or N/A where applicable. Incomplete forms will be returned and will cause a delay in the verification and payment process. Failure to submit this form will affect claim payment. Notice to Clients: You may be contacted to verify receipt of the equipment provided. Aviso al cliente: Esposible que lo contactemos para verificar que recibió equipo.
Effective Date_06/01/2008/Revised Date_08/20/2008

DME Certification and Receipt Form
Certificación y Recibo de Equipo Médico Duradero (DME)
(Page 2 of 3—Required only for requests containing six or more items)
Client Information Medicaid ID Number: Provider Information Provider Name: NPI/API: Product Information (Continuation)Date of Service: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description: Procedure Code: Description:...