WORKSHEET: NIH GDS Institutional Certification

Modifiers (if applicable): Enter up to 4 modifiers as applicable. DME providers enter modifier as appropriate based upon the Durable Medical Equipment and Supplies Listing/Appendix B found in the DMAS DME provider manual information. Units Requested: Based on physician’s orders, plan of care, or CMN provide the number of services/visits ... ................
................

In order to avoid copyright disputes, this page is only a partial summary.