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 tool used to track and summarize durable medical equipment (DME) for individuals with intellectual or developmental disabilities. This form helps solve the problem of keeping accurate records of DME usage and costs over time.

This summary sheet requires information such as client name, begin date, cost, service description, provider, and receipt date. The form also includes sections for annual, year-to-date, and total costs, as well as a space to note any variances from previous years. Common scenarios of use include tracking DME usage for individuals receiving services under the ICF/IID program.

The TX HHS Form 4116-DME is intended for use by healthcare providers, service coordinators, or other professionals responsible for managing DME for clients with intellectual or developmental disabilities. By using this form, these professionals can easily summarize and track DME usage, helping to ensure that clients receive the necessary equipment and services while also keeping accurate records.