Link to the Web site for the Centers for Medicare and Medicaid Services

New DME MAC Forms

The following forms are to be used for dates of service on or after January 1, 2007. For dates of service on or after October 1, 2006 through December 31, 2006, suppliers have the option to submit either the old DMERC forms or the new DME MAC forms.

DESCRIPTION	DME MAC Form #	CMS Form #
Continuation Form	11.02	854
Enteral and Parenteral Nutrition	10.03	10126
External Infusion Pumps	09.03	10125
Osteogenesis Stimulators	04.04C	847
Oxygen	484.03	484
Pneumatic Compression Devices	04.04B	846
Seat Lift Mechanisms	07.03A	849
Transcutaneous Electrical Nerve Stimulator (TENS)	06.03B	848

Old DMERC Forms The following forms are to be used for dates of service prior to October 1, 2006. For dates of service on or after October 1, 2006 through December 31, 2006, suppliers have the option to submit either the old DMERC forms or the new DME MAC forms.
DESCRIPTION	DMERC Form #	CMS Form #
Enteral Nutrition	10.02B	853
External Infusion Pump	09.02	851
Hospital Beds	01.02A	841
Immunosuppressive Drugs	08.02	N/A
Lymphedema Pumps (Pneumatic Compression Devices)	04.03B	846
Osteogenesis Stimulators	04.03C	847
Oxygen	484.2	484
Parenteral Nutrition	10.02A	852
Power Operated Vehicles	07.02B	850
Seat Lift Mechanisms	07.02A	849
Support Surfaces	01.02B	842
Transcutaneous Electrical Nerve Stimulators (TENS)	06.02B	848
Wheelchairs, Manual	02.03B	844
Wheelchairs, Motorized	02.03A	843
Wheelchairs, Section C Continuation Form	11.01	854

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New DME MAC Forms

Old DMERC Forms