Certification type and date
Initial, Revised or Recertification, each with a date. The instructions say a revised or recertification DIF always gives the initial date as well.
CMS-10126
DME Information Form - Enteral and Parenteral Nutrition DME 10.03
- Agency
- CMS
- Revision
- 06/19
- Fillable fields
- 96
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10126: DME Information Form for Enteral and Parenteral Nutrition (DME 10.03)
Form CMS-10126 is the DME Information Form (DIF) for Enteral and Parenteral Nutrition, labeled DME 10.03, from the Centers for Medicare & Medicaid Services. The form says all information on it may be completed by the supplier, and its instructions say the supplier's signature certifies that the information is an accurate representation of the situation under which the item or service is billed.
The form records whether it is an initial, revised or recertification DIF, then the patient, supplier, place of service, facility and physician details, the estimated length of need and the diagnosis codes. Questions 1 to 6 are for enteral nutrition and questions 6 to 9 are for parenteral nutrition. It ends with a supplier attestation, signature and date. The second page holds the instructions for each block.
The special instructions on the CMS page say the form must be used starting January 1, 2007. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10126
Patient and supplier
The patient's name, address, telephone and Medicare ID as shown on the Medicare card, and the supplier's name, address, telephone and NSC or NPI number. The instructions use the qualifier XX before a 10-digit NPI and 1C before a legacy number.
Place of service, facility and physician
A place of service code (the instructions give 12 for the patient's home, 31 for a skilled nursing facility and 65 for an ESRD facility), the facility name and address if applicable, and the physician's details.
Item codes and patient details
Supply item or service procedure codes that require a DIF, the patient's date of birth, sex, height in inches and weight in pounds, estimated length of need from 1 to 99 months (99 means lifetime) and diagnosis codes.
Questions 1 to 9
Medical record documentation, tube feeding, product codes, calories per day, method of administration, days per week, formula components (amino acid, dextrose and lipids) and the route of administration.
Supplier attestation
The supplier certifies that the information is true, accurate and complete to the best of its knowledge, then signs and dates the form.
The second page of the form explains each block.
How to fill out Form CMS-10126
- 1
Pick the certification type
Enter the date needed initially. For a revised DIF or a recertification, the instructions say to add that date next to the initial date.
- 2
Fill in the patient and supplier blocks
Enter the patient's name, permanent legal address, phone and Medicare ID as on the Medicare card and claim form, then the supplier's details and NSC or NPI number.
- 3
Add place of service and physician
Enter the place of service code, the facility name and address if the place of service is a facility, and the physician's name, address, phone and UPIN or NPI.
- 4
List the codes and patient details
The instructions say to list only procedure codes that require a DIF, then give date of birth, sex, height, weight, length of need and diagnosis codes.
- 5
Answer the questions that apply
Questions 1 to 6 for enteral nutrition and 6 to 9 for parenteral nutrition. Check Y or N, pick a number where one is offered, or fill in the blank.
- 6
Sign the attestation
The instructions say the supplier signs and dates the form after it is completed, verifying the attestation.
Why fill Form CMS-10126 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the form says
Where to send it
The form does not print a submission address. The CMS address on the instructions page is for comments on the form only. The form says not to submit claims to that address and points to medicare.gov for claim filing information.
Place of service codes
The instructions refer to the DMERC supplier manual for a complete list of place of service codes.
OMB number and dates
The form shows OMB No. 0938-0679 with an expiration of 02/2024. The CMS page lists a revision date of 2017-02-01 and an O.M.B. expiration date of 2020-02-01.
Liability
The attestation says any falsification, omission or concealment of material fact associated with billing the service may subject the supplier to civil or criminal liability.
Time to complete
The form estimates an average of 12 minutes per response, including reviewing the instructions and gathering the information.
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Who uses Form CMS-10126?
The form is completed and signed by the supplier of enteral or parenteral nutrition.
Official sources and the blank
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Questions about Form CMS-10126
Who fills out Form CMS-10126?
The form says all information on it may be completed by the supplier. The supplier also signs and dates the attestation at the bottom.
Which questions are for enteral and which for parenteral nutrition?
The form says to answer questions 1 to 6 for enteral nutrition and 6 to 9 for parenteral nutrition. Question 6, days per week administered or infused, is in both sets.
What is the difference between initial, revised and recertification?
The instructions say an initial DIF gives the date needed initially. A revised DIF is completed when the physician changes the order based on the patient's changing clinical needs, and a recertification adds a recertification date. Both of those also give the initial date.
How do I enter an NPI on the form?
The instructions say to use the qualifier XX followed by the 10-digit NPI. A legacy NSC number uses 1C followed by 10 digits, and a physician UPIN uses 1G followed by 6 digits.
What does estimated length of need mean?
It is the number of months the item is needed, from 1 to 99. The form says 99 means lifetime.
Where do I send Form CMS-10126?
The form does not print a submission address. It says not to submit claims to the CMS comments address on page 2, and points to medicare.gov for information on claim filing.