Certificate Of Medical Necessity Form For Initial Referral/orders Outpatient Physical/occupational/speech Therapy

ADVERTISEMENT

HealthSystems of Mississippi
HealthSystems of Mississippi Medicaid
460 Briarwood Drive
Certificate of Medical Necessity Form
Suite 300
For Initial Referral/Orders
Jackson, MS 39206
Outpatient Physical/Occupational/Speech Therapy
Section A: Beneficiary and Provider Information
Patient Name: ______________________________
Ordering MD/NP/PA Name (First and Last):
Medicaid #:
______________________________________________
/
/
Date of Birth:
Medicaid ID#:
Telephone #:
Age:
Sex:
(M or F)
-
-
/
/
Ext.
Date of last visit:
Section B: Clinical Information
(THIS SECTION MUST BE COMPLETED BY THE PHYSICIAN/NP/PA.)
ICD-9-CM
Diagnoses
Clinical Summary: Record relative history indicating patient’s need for each requested therapy service by discipline, i.e., physical,
occupational and/or speech therapy.
Physician/Nurse Practitioner/Physician Assistant Order(s):
Section C: Physician//Nurse Practitioner/Physician Assistant Attestation, Signature and Date
A physician, nurse practitioner, or physician assistant who attests to the medical necessity of the prescribed services, who knowingly or
willfully makes, or causes to be made any false statement or representation of a material fact in any application for Medicaid benefits or
Medicaid payments, may be prosecuted under federal and/or state criminal laws and/or may be subject to civil monetary penalties and/or
fines. I hereby certify that I am the prescribing physician/nurse practitioner/physician assistant identified in Section A and that I have
prescribed the orders listed in Section B of this form. I certify that the medical necessity information in Section B is true, accurate and
complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to civil
monetary penalties, fines, or criminal prosecution.
_________________________________________________________________
_____________________
Signature and Title of Prescribing Provider
Date
Effective: 01/01/09
Certificate of Medical Necessity Form for Initial Referral/Orders
Revised:
Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Certificate Of Medical Necessity (cmn) For Transcutaneous Electrical Nerve Stimulator (tens) Certificate Of Medical Necessity (cmn) For Transcutaneous Electrical Nerve Stimulator (tens) Medical
Form Map 1000b - Certificate Of Medical Necessity - Department For Medicaid Services Form Map 1000b - Certificate Of Medical Necessity - Department For Medicaid Services Medical
Certificate Of Medical Necessity Form Certificate Of Medical Necessity Form Medical
Physician's Orders And Certificate Of Medical Necessity Form Physician's Orders And Certificate Of Medical Necessity Form Medical
Medicaid Certificate Of Medical Necessity Form - South Carolina Department Of Health Medicaid Certificate Of Medical Necessity Form - South Carolina Department Of Health Legal
Certificate Of Medical Necessity Durable Medical Equipment And Supplies Template Certificate Of Medical Necessity Durable Medical Equipment And Supplies Template Medical
Certificate Of Medical Necessity For Home And Vehicle Modification Template Certificate Of Medical Necessity For Home And Vehicle Modification Template Medical
Form Cms-10269 - Certificate Of Medical Necessity - Dme 03.03 - Positive Airway Pressure (pap) Devices For Obstructive Sleep Apnea Form Cms-10269 - Certificate Of Medical Necessity - Dme 03.03 - Positive Airway Pressure (pap) Devices For Obstructive Sleep Apnea Medical
Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Legal
Certificate Of Medical Necessity Certificate Of Medical Necessity Medical

Related Categories

Parent category: Medical
Download
Go