TX HHS Form 4116-DME. ICF/IID Durable Medical Equipment Summary Sheet

The TX HHS Form 4116-DME, ICF/IID Durable Medical Equipment Summary Sheet, is a practical tool designed to help track and manage durable medical equipment (DME) for individuals with intellectual or developmental disabilities. This form is typically used by healthcare providers, caregivers, or case managers to document the DME needs of clients receiving services under the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) program.

The form requires essential information such as client name, begin date, cost, and provider details. It also includes spaces to record DME item/service descriptions, costs, and receipt dates. This summary sheet helps users monitor and track the DME needs of clients over time, facilitating more effective care planning and management.

Key features of this form include:

• Recording client information, including name and begin date
• Tracking DME items/services, costs, and receipt dates
• Monitoring year-to-date and total costs for each client