Form Dmas-352 - Certificate Of Medical Necessity Template printable pdf download

Form Dmas-352 - Certificate Of Medical Necessity Template

VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

CERTIFICATE OF MEDICAL NECESSITY

DURABLE MEDICAL EQUIPMENT AND SUPPLIES

INDIVIDUAL DATA

SERVICING PROVIDER

ECTION

I.D. #

Note: The CMN can now be used

Name

in place of DMAS-115. The

original requirements for justification

D.O.B.

Contact Person

Phone #

still apply. Additional questions

INDIVIDUAL INFORMATION

have been added to the CMN.

ECTION

Answer all questions that are applicable to DME service being requested.

DESCRIPTION/ADDITIONAL INFORMATION:

If answer is yes, you must describe/attach additional information.

(Additional space on reverse)

Does patient:

YES

have impaired mobility?

have impaired endurance?

have restricted activity?

have skin breakdown? (Describe site, size,

depth and drainage)

have impaired respiration? (Identify most

recent PO 2 ________/Saturation level _______

for patients on oxygen)

require assistance with ADL's?

have impaired speech?

***

8. a) require nutritional supplements? (If yes,

answer b and c below.)

b) sole source or primary source (circle one)

c) height _________ weight _____________

IS THE ITEM SUITABLE FOR USE IN HOME, & DOES THE INDIVIDUAL/CAREGIVER DEMONSTRATE WILLINGNESS/ABILITY TO USE THE EQUIPMENT? YES

Date individual last examined by physician

ICD Code

Clinical Diagnoses

Date of Onset

Less than 6 months

Greater than 6 months

III

(

)

ECTION

ADDITIONAL SPACE ON REVERSE

Begin

Length

Quantity

Service

HCPCS

Item Ordered

Ordered/

Frequency of Use*

Date

Code

Description*

Time

x1 Month*

Justification/Comments/

Needed

Calories Per Day

PHYSICIAN CERTIFICATION (

)

ECTION

MUST BE SIGNED AND DATED BY

HYSICIAN

I CERTIFY THAT THE ORDERED DME AND SUPPLIES ARE PART OF MY TREATMENT PLAN AND, IN MY OPINION, ARE MEDICALLY NECESSARY.

ORDERING PHYSICIAN'S NAME (print)

PHYSICIAN'S SIGNATURE*

DATE*

I.D.#

PHONE #

*Required fields. If any of these fields are blank the CMN is not valid. The other sections of the CMN can be documented on the CMN or in supporting documentation.

Physician’s signature does not guarantee payment unless all documentation requirements are met. Issuance of a PA does not guarantee payment. Payment is contingent upon

all appropriate documentation being readily available for review. ***Complete diet order must be indicated in Section III

DMAS-352, Revised 8/2015