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...Form approved omb department of health and human services no centers for medicare medicaid expires dme information cms enteral parenteral nutrition all on this may be completed by the supplier certification type date initial revised recertification patient name address telephone id nsc or applicable npi number legacy supply item service pt dob sex m f ht in wt lbs place procedure code s facility physician upin if see reverse est length need months lifetime diagnosis codes answers answer questions check y yes n unless otherwise noted o is there documentation medical record that supports having a permanent non function disease structures normally permit food to reach absorbed from small bowel being provided administration via tube i e gastrostomy jejunostomy nasogastric print product b calories per day each corresponding method syringe gravity pump oral drinking days week administered infused enter gastrointestinal tract causing malabsorption severe enough prevent maintenance weight stre...