In the past few weeks we have been asked how to fill out the extension form for the upcoming HIPAA format.  As a result, we have created this page to help.  

The answers listed below are only examples of how we expect the average TeamDME! user to apply for the HIPAA extension.  Please consult your HIPAA legal counsel to make sure your answers are correct for your company.  If you need to download and fill out the form, please click here.

1. Name of Covered Entity
    Your Company Name
2. Tax Identification
    Your EIN Number
3. Medicare Identification Number(s)
    Your Medicare Number
4. Type of Covered Entity
    Health Care Provider, DME Supplier
5. Authorized Person
    Your Name
6. Title
    Your Title
7. Street
    Your Address
8. City
    Your City
9. Telephone Number
    Your Phone Number
10. Reason that you do not expect to be compliant with the HIPAA Electronic Health Care Transactions and Code Sets         standards by October 16, 2002.
    Waiting for vendor(s) to provide software
    Need more time to complete implementation
11. Implementation Budget
    Less than $10,000 (much less)
12. Please indicate whether you have completed this Awareness phase of the Implementation Strategy.
    Yes
13.
14. Projected/Actual Completion Date
    Oct, 2001
15. Please indicate whether you have completed this Operational Assessment phase of the Implementation Strategy.
    Yes
16. 
17.
18.
19.
20. Projected/Actual Completion Date
    Jan, 2002
21. Please indicate whether you have completed this Development and Testing phase of the Implementation Strategy.
    No
22. Completed software development/installation?
    Initiated but not completed
23. Completed staff training?
    No
24. Projected/Actual Development Start Date
    Jan, 2002
25. Projected/Actual Initial Internal Software Testing Start Date
    Oct, 2002 (or when you expect your DMERC to accept production claims)
26. Projected/Actual Testing Completion Date
    Nov, 2002 (or when you expect to begin sending production claims)