DMEPOS
Client Discovery Form

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

Section 2: Ownership and Signing Authority

Main Accreditation / Project Contact

Section 3: NPI / NPPES Verification

Section 4: Holding Company Information

Section 5: Location Documentation

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

Section 8: Insurance and Bonding

Section 9: Existing Accreditation-Related Materials

Section 10: Initial Patient Record Status

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.

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.

Section 13: Attestation

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

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

Or Upload Signature Image

JPG, PNG accepted

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

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