Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

OMB 0938-0679

This information is needed to correctly process claims and ensure that claims are properly paid. These forms contain medical information necessary to make an appropriate claim determination. Suppliers and physicians will complete these forms and as needed supply additional routine supporting documentation to process claims.

The latest form for Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation expires 2023-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10126 Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation Form and Instruction
Form CMS-484 Oxygen and Supplies Form and Instruction
CMS-484-10126 - Supporting Statement Part A.docx Supporting Statement A
CMS-484-10126 - Appendix A - Response to Public Comments.pdf Supplementary Document
Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation Form and Instruction
Oxygen and Supplies Form and Instruction

All Historical Document Collections

202002-0938-014 Approved without change	Extension without change of a currently approved collection	2020-02-27
201605-0938-012 Approved with change	Revision of a currently approved collection	2016-05-12
201410-0938-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-10-09
201303-0938-018 Approved without change	Reinstatement with change of a previously approved collection	2013-03-29
201001-0938-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2010-01-11
200909-0938-001 Approved without change	Revision of a currently approved collection	2009-09-10
200809-0938-017 Approved with change	Revision of a currently approved collection	2008-09-30
200510-0938-017 Approved without change	No material or nonsubstantive change to a currently approved collection	2005-10-18
200501-0938-005 Approved with change	Revision of a currently approved collection	2005-01-26
200303-0938-007 Approved with change	Revision of a currently approved collection	2003-03-21
200207-0938-006 Approved with change	Reinstatement without change of a previously approved collection	2002-07-10
199703-0938-002 Approved without change	Revision of a currently approved collection	1997-03-07
199602-0938-003 Approved without change	Extension without change of a currently approved collection	1996-02-09
199510-0938-001 Approved without change	Existing collection in use without an OMB Control Number	1995-10-11

OMB Details

Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-846	CMS for PNEUMATIC COMPRESSION DEVICES	Fillable Fileable Signable	Form and instruction
Form CMS-854	CMS-854 -- CONTINUATION FORM	Fillable Fileable	Form and instruction
Form CMS-10126	CMN for ENTERAL AND PARENTERAL NUTRITION	Fillable Fileable Signable	Form and instruction
Form CMS-10125	CMN for EXTERNAL INFUSION PUMPS	Fillable Fileable Signable	Form and instruction
Form CMS-849	CMN for SEAT LIFT MECHANISMS	Fillable Fileable Signable	Form and instruction
Form CMS-848	CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)	Fillable Fileable Signable	Form and instruction
Form CMS-847	CMN for OSTEOGENESIS STIMULATORS	Fillable Fileable Signable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.