In the listing, there's some information regarding the form certificate necessity. It is suggested that you read through this information before you start editing the file.
| Question | Answer |
|---|---|
| Form Name | Form Certificate Necessity |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | blank certificate of medical necessity, certificate necessity, certificate necessity dme, health form necessity |
|
Form Approved OMB |
DEPARTMENT OF HEALTH AND HUMAN SERVICES |
No. |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
Expires 02/2024 |
CERTIFICATE OF MEDICAL NECESSITY
DME 11.02
PATIENT NAME
MEDICARE ID
SECTION C Narrative Description of Equipment and Cost (continued)
(1)Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule Allowance for each item, accessory and option. (see instructions on back.)
SECTION D |
PHYSICIAN Attestation and Signature/Date |
I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.
PHYSICIAN’S SIGNATURE_________________________________________________________________________ DATE _____/_____/_____
Form
INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY
SECTION C CONTINUATION FORM
SECTION C: |
(To be completed by the supplier) |
NARRATIVE |
Provide (1) a narrative description of the item(s) ordered, as well as all options, accessories; (2) the product, model and |
DESCRIPTION OF |
serial number of the product being delivered (if applicable); (3) the supplier’s charge for each item, option, accessory; and |
EQUIPMENT & COST: |
(4) the Medicare fee schedule allowance for each item/option/accessory/supply/drug, if applicable. |
SECTION D: |
(To be completed by the physician) |
PHYSICIAN |
The physician's signature certifies(1) the CMN which he/she is reviewing includes Sections A, B, C and D;: (2) the answers |
ATTESTATION: |
in Section B are correct; and (3) the |
PHYSICIAN SIGNATURE |
After completion and/or review by the physician of Sections A, B and C, the physician must sign and date the CMN in |
AND DATE: |
Section D, verifying the Attestation appearing in this Section. The physician's signature also certifies the items ordered are |
|
medically necessary for this patient |
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.
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