Fillable Dmerc 02.03b - Certificate Of Medical Necessity printable pdf download

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION

OMB NO. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY

DMERC 02.03B

MANUAL WHEELCHAIRS

SECTION A

Certification Type/Date:

INITIAL ___/___/___

REVISED ___/___/___

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

Alba International Trading Corp.

2308 Knapp Street.

Brooklyn ,NY 11229

(718) 252-4120

1023232501

(__ __ __) __ __ __ - __ __ __ __ HICN ____________________________

(__ __ __) __ __ __ - __ __ __ __ NSC # __________________________________

PT DOB ____/____/____; Sex ____ (M/F) ;

HT.______(in.) ;

WT._____(lbs.)

PLACE OF SERVICE ________

HCPCS CODE

NAME and ADDRESS of FACILITY if applicable (See

K0003

PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN NUMBER

Reverse)

(__ __ __) __ __ __ - __ __ __ __ UPIN # __________________________________

SECTION B

Information in This Section May Not Be Completed by the Supplier of the Items/Supplies.

EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME)

DIAGNOSIS CODES (ICD-9): _________ _________ _________ _________

ANSWER QUESTIONS 1, 5, 8 AND 9 FOR MANUAL WHEELCHAIR BASE, 1-5 FOR WHEELCHAIR

ITEM ADDRESSED

ANSWERS

OPTIONS/ACCESSORIES.

(Circle

for Yes,

for No, or

for Does Not Apply, unless otherwise noted.)

Manual Whlchr Base And

Y N D

1. Does the patient require and use a wheelchair to move around in their residence?

All Accessories

Reclining Back

Y N D

2. Does the patient have quadriplegia, a fixed hip angle, a trunk cast or brace, excessive extensor

tone of the trunk muscles or a need to rest in a recumbent position two or more times during the

day?

Elevating Legrest

Y N D

3. Does the patient have a cast, brace or musculoskeletal condition, which prevents 90 degree flexion

of the knee, or does the patient have significant edema of the lower extremities that requires an

elevating legrest, or is a reclining back ordered?

Adjustable Height Armrest

Y N D

4. Does the patient have a need for arm height different than that available using non-adjustable

arms?

Reclining Back;

5. How many hours per day does the patient usually spend in the wheelchair? (1–24) (Round up to the

_________

Adjustable Ht. Armrest;

next hour)

Any Type Ltwt. Whlchr

Y N D

8. Is the patient able to adequately self-propel (without being pushed) in a standard weight manual

wheelchair?

Any Type Ltwt. Whlchr

Y N D

9. If the answer to question #8 is "No," would the patient be able to adequately self-propel (without

being pushed) in the wheelchair which has been ordered?

NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):

NAME: ____________________________________________ TITLE: ________________________

EMPLOYER: ______________________

SECTION C

Narrative Description of Equipment and Cost

(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.) If additional space is needed, list wheelchair base

and most costly options/accessories on this page and continue on HCFA Form 854.

K0003 - Lightweight wheelchair

E0973 - ADJUSTABLE HEIGHT ARMREST

E0990 - El.legrest

E0971 - ANTI-TIPPING DEVICE

E2601 - Seat cushion

E2611 - Back cushion

E0978 - Belt

E0974 - Anti-rolling device

r r C

HCFA F

854

HECK HERE IF ADDITIONAL OPTIONS

ACCESSORIES ARE LISTED ON ATTACHED

ORM

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 _____/_____/_____

(SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)

CMS 844 (5/97)