Onboarding & Documentation Checklist

DMEPOS Supplier Accreditation - Onboarding & Documentation Checklist

Please provide the information and documents below so we can verify business identity, ownership, location, licensure, product scope, payer status, and initial accreditation readiness.

Section 1: Business and Tax Verification

Legal Business Name

DBA / Trade Name, if applicable

Entity Type

EIN / Tax ID

Has there been any amendment, name change, address change, ownership change, or restructuring?

Business Change Notes, if applicable

Business and Tax Documents

Articles of Incorporation or Articles of Organization

Certificate of Good Standing / Colorado Secretary of State Record

DBA / Trade Name Registration

IRS EIN Confirmation Letter CP 575 or 147C

Signed Current W-9 form

IRS S-Corp Election Confirmation, if available

Amendments / Name Change / Address Change / Ownership Change Documents

Section 2: Ownership and Signing Authority

Number of Owners

List of Officers, Directors, Managers, and Key Leadership Personnel

Who is authorized to sign ACHC, licensure, payer enrollment, lease, insurance, and regulatory documents?

Main Accreditation / Project Contact

Contact Name

Contact Title

Contact Phone

Contact Email

Ownership and Signing Authority Documents

Current Ownership List with Ownership Percentages

Corporate Bylaws / Shareholder List / Stock Ledger / Shareholder Agreement

Operating Agreement or Membership Schedule

Signing Authority Documentation

Section 3: NPI / NPPES Verification

Organization NPI Number

Legal Business Name Listed in NPPES

DBA / Other Name Listed in NPPES

Taxonomy Code

Practice Location Address

Mailing Address

Authorized Official Listed in NPPES

Organization NPI Confirmation or NPPES Screenshot

Upload NPPES Confirmation / Screenshot

Section 4: Holding Company Information

Holding Company Legal Name

Holding Company DBA / Trade Name (if applicable)

Holding Company Entity Type

Holding Company State of Formation

Number of Holding Company Owners / Officers / Directors / Managers / Controlling Persons

Name of Authorized Person

Designation / Title

Ownership Change, Acquisition, Merger, Restructuring or EIN Change Details

Holding Company Supporting Documents

Secretary of State Record / Certificate of Good Standing

Documentation Showing Holding Company Owns the DME Company

Ownership Chart Showing Relationship Between Holding Company, DME Company and Affiliates

Holding Company Ownership / Leadership List

Signing Authority Documentation

Management, Shared Services, Lease/Sublease, Staffing, Billing, Administrative or Operational Agreements

Section 5: Location Documentation

DME Location Address

Location Documents

Lease, Sublease, Deed, or Proof of Ownership

Lease Amendments or Renewals

Landlord Approval for DME / Medical Supply Business Use

Proof of Address / Utility Bill / Business Mail

Certificate of Occupancy / Zoning Approval / Local Business License

Facility Photos

Upload Floor Plan (Upload the DME Floor Plan, Interior & Exterior Both DME Facility Photos, Photo of clearly posted DME signage with hours of operation, DME Entrance)

Section 6: Product Scope / Item List

Please fill & upload the Product Scope Worksheet on ShareFile - Onboarding folder. This worksheet includes specific information for all your current & potential supplies.

Section 7: Payer / Medicaid Enrollment Status

Current Company Status

Enrolled with Medicaid but pending revalidation Unable to bill Medicaid until revalidation is approved Claims denied due to incomplete revalidation Inactive or terminated with Medicaid Private pay / cash only Enrolled with commercial payers Planning future payer enrollment

Medicaid Provider ID, if available

Payer / Medicaid Notes

Payer / Medicaid Documents

Medicaid Approval Letter or Provider ID

Medicaid Provider Portal Screenshot

Medicaid Revalidation Application Status

Medicaid Deficiency Notice / Request for Additional Information

Commercial Payer Contracts or Approval Letters

Payer Credentialing / Enrollment / Site Visit Correspondence

Section 8: Insurance and Bonding

Insurance Documents

General Liability Insurance Certificate or Declaration Page

Professional Liability / Malpractice Coverage

Product Liability Coverage

Workers’ Compensation Policy or Exemption

Commercial Auto Policy

Payer-Required Insurance Certificates

Insurance Notes

Section 9: Existing Accreditation-Related Materials

Have accreditation-related materials already been created?

Accreditation-Related Documents

Existing Policies and Procedures

Existing Patient / Client Packet or Welcome Packet

Existing Forms, Logs, Templates, or Training Materials

HIPAA / Compliance / Emergency Preparedness / Infection Control / QAPI Materials

Accreditation Materials Notes

Section 10: Initial Patient Record Status

Has the company served any DME patients / clients yet?

Number of Active DME Patients / Clients

Total DME Patients / Clients Served to Date

Does the company have at least five actual patient / client records available for accreditation review?

Payer Types Represented

Private Pay / Cash Medicare Medicaid Commercial Insurance Other

Product Categories Represented in Patient Records

Have any claims been billed or paid?

Patient Record Status Notes

Section 11: Vendor / Supplier Information

Please complete this section for each vendor, supplier, distributor, manufacturer, drop-ship partner, delivery contractor, billing vendor, software vendor, or other company involved in your DME business.

Please add a separate entry for each vendor.

Number of Vendors

Section 12: EHR System / Record Storage

Please complete this section so we can understand how patient/client records, business records, accreditation documents, and compliance documentation are stored and maintained.

Do you currently use an EHR, EMR, billing system, CRM, or other software system to store patient/client records?

System Name

What types of records are stored in the system?

Patient/client intake records Orders/prescriptions Delivery tickets / proof of delivery Product education documents Patient/client packet acknowledgments Insurance/payer information Billing/claims information Prior authorization documents Patient communication notes Complaint records Incident/adverse event records Equipment tracking records Inventory records Vendor documents Personnel/training records Policies and procedures QAPI/performance improvement documents Emergency preparedness documents HIPAA/compliance documents Other

If you do not use an EHR or software system, how are records currently stored?

Paper files Scanned documents Shared drive Cloud storage Email folders Excel spreadsheets Billing portal Vendor portal Other

Please briefly describe your current record storage process

Who has access to patient/client records?

Are patient/client records stored securely?

Please describe how records are secured

Can records be exported, printed, or downloaded for accreditation review if needed?

Section 13: Attestation

By submitting this form, the organization certifies that the information provided is accurate and complete to the best of its knowledge.

Authorized Representative Name

Authorized Representative Title

Submission Date

Electronic Signature

Draw Signature Upload Signature

Draw your signature using your mouse, trackpad, or touchscreen.

Or Upload Signature Image

JPG, PNG accepted

I confirm that the information submitted is accurate and complete.

This onboarding checklist is used to determine business identity, ownership, licensure, payer status, and initial ACHC accreditation readiness.

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