Cms-10125 -- External Infusion Pumps

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0679

DME INFORMATION FORM
CMS-10125 — EXTERNAL INFUSION PUMPS

DME 09.03

Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN _______________________

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

PLACE OF SERVICE______________

HCPCS CODE

__________
__________
__________
__________

NAME and ADDRESS of FACILITY
if applicable (see reverse)

ANSWERS

PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable
NPI NUMBER or UPIN

(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
ANSWER QUESTIONS 1 - 4 FOR EXTERNAL INFUSION PUMP.

HCPCS CODE:

1. Provide the HCPCS code(s) for the drug(s) that requires the use
of the pump.

a) _______________________________________________________
b) _______________________________________________________
c) _______________________________________________________

a) _______________________________________________________

2. If a NOC (not otherwise classified) HCPCS code is listed in
question 1, print name of drug.

b) _______________________________________________________
c) _______________________________________________________
1

2

3

4

3. Circle number for route of administration?
1 — Intravenous 2 — Subcutaneous 3 — Epidural 4 — Other

1

2

4. Circle number for method of administration?
1 – Continuous

2 – Intermittent

Supplier Attestation and Signature/Date
I certify that I am the supplier identified on this DME Information Form and that the information provided is true, accurate, and complete, to the best
of my knowledge. I understand that any falsification, omission, or concealment of material fact associated with billing this service may subject me to
civil or criminal liability.
SUPPLIER SIGNATURE_________________________________________________________________________ DATE _____/_____/_____
Form CMS-10125 (09/05) EF 08/2006

INSTRUCTIONS FOR COMPLETING DME INFORMATION FORM
FOR EXTERNAL INFUSION PUMPS (CMS-10125)
CERTIFICATION
TYPE/DATE:

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

Indicate the patient’s name, permanent legal address, telephone number and his/her health
insurance claim number (HICN) as it appears on his/her Medicare card and on the claim form.

SUPPLIER
INFORMATION:

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

HCPCS CODES:

List all HCPCS procedure codes for items ordered that require a DIF. Procedure codes that do
not require certification should not be listed in this section of the DIF.

PATIENT DOB,
HEIGHT, WEIGHT
AND SEX:

Indicate patient’s date of birth (MM/DD/YY) and sex (male or female); height in inches
and weight in pounds, if required.

PHYSICIAN NAME,
ADDRESS:

Indicate the physician’s name and complete mailing address.

PHYSICIAN
INFORMATION:

Accurately indicate the treating physician’s Unique Physician Identification Number (UPIN) 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 UPIN number, use the qualifier 1G followed
by the 6-digit number. (For example. 1Gxxxxxx)

PHYSICIAN’S
TELEPHONE NO:

Indicate the telephone number where the physician can be contacted (preferably where records
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, circling “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
ATTESTATION:

The supplier’s signature certifies that the information on the form is an accurate representation
of the situation(s) under which the item or service is billed.

SUPPLIER
SIGNATURE
AND DATE:

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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
this information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form,
please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.
Form CMS-10125 (09/05) INSTRUCTIONS EF 08/2006