DME Licensing, Accreditation & Credentialing – Client Discovery Form

This form focuses on gathering information and documents to verify home health agencies business identity, ownership, location, licensure, home health services scope, accreditation readiness and Medicare enrollment requirements.

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

• Submission does not guarantee accreditation approval, network participation, or reimbursement.

1. Intake Overview

Client / Project Type *

New DME business Existing supplier Adding DME services Acquisition / ownership change

2. Primary Client Contact and Organization Basics

Client Name *

Main Point of Contact - Name *

Main POC Title / Role *

Main POC Phone * Direct line preferred

Main POC Email *

Secondary Contact, If Available

Secondary Contact Name

Secondary Contact Title / Role

Secondary Contact Phone

Secondary Contact Email

Full Legal Organization Name * As shown on formation and tax documents

DBA / Trade Name, If Applicable

State(s) of Operation *

Check every state where the organization operates.

Primary Location / Service Area * Select service area type Local / City County Regional Statewide Multi-State Nationwide Other

Website URL, If Available

Planned Opening / Expansion Date Use the closest estimated date when the exact date is unknown.

3. Business Identifiers and Location

Federal Tax ID / EIN *

Group / Organization NPI

Physical / Service Location Address *

Street Address *

Suite / Unit / Building

City *

Physical / Service Location State(s) *

Check only the state(s) that apply to this physical or service location.

ZIP Code *

Mailing Address

Business Phone / Fax

Business Phone

Phone Extension

Business Fax

Business Email

4. Scope of Work

Services Purchased / Requested *

State DME / HME license application License renewal License amendment / change of information DME accreditation - initial Accreditation renewal Accreditation corrective action / remediation Medicare DMEPOS enrollment support Medicaid enrollment support Consulting / readiness review Other

Please specify other service

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Number of Locations in Scope *

Number of States in Scope *

DME / DMEPOS Product Categories *

Operating / Fulfillment Model

Storefront Office Warehouse Patient pickup Company delivery Drop-ship Common carrier

5. Current State Licenses and Registrations

States Where the Organization Currently Holds a DME / HME License or Registration *

+ Add Another License / Registration If the organization has no current license or registration, select N/A in the status field.

Any Current License Renewals or Deficiencies?

No Yes - explain below

Explanation

Any Pending Applications?

No Yes - list state(s) and status

Pending Application Details

Current License Issues / Notes

Current Professional / Facility Licenses

6. Target States for Licensing and Accreditation

Target States for Licensing

Check only the states included in the licensing scope.

Target States for Accreditation

Check only the states included in the accreditation scope.

Refer to the executed service agreement for the final approved state scope.

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Target State Priority / Phases

7. Current and Expected DME Accreditation

Current Accreditation Organization Select organization ACHC CHAP The Compliance Team Joint Commission None Other

Specify Other Organization

Current Accreditation Status Select status Not started In progress Accredited Renewal Corrective action

Accreditation Number

Accreditation Effective Date

Expiration / Renewal / Survey Date

Expected / Requested Accreditation Organization Select organization ACHC CHAP The Compliance Team Joint Commission Undecided Other

Specify Other Organization

Accreditation Scope Expected

8. Attestation & Signature

Client Name *

Authorization Date *

Authorized Representative Name *

Authorized Representative Title *

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Signature Method *

Draw Signature Upload Signature

Clear Signature Draw using a mouse, touchpad, stylus, or touchscreen.

Upload Signature Image Accepted formats: PNG, JPG, or JPEG.

Signature Date *

I certify that all information provided in this application is true, complete, and accurate.

Not submitted

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