Form Dmas-352 - Certificate Of Medical Necessity Template Page 2
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1
2INDIVIDUAL NAME
VMAP #
SERVICING PROVIDER
PROVIDER
NAME
ID#
DESCRIPTION/ADDITIONAL INFORMATION
SECTION II (continued)
*For Nutritional Supplements assessor must document formula tolerance and tube/stoma site assessment if applicable. This can be documented on the
CMN or in the supporting documentation, signed and dated by the physician. ***Complete diet order must be indicated in Section III
SECTION III (continued)
Begin
Length
*Quantity
Service
HCPCS
*Item Ordered
of
Ordered/
Frequency of Use*
Date
Code
Description
Time
x1 Month
Justification/Comments/
Needed
Caloric Order Per Day
S
IV
PHYSICIAN CERTIFICATION (
)
ECTION
MUST BE SIGNED AND DATED BY PHYSICIAN
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 #
Section I
INDIVIDUAL DATA
Section III
•
•
Complete 12-digit individual identification number
Begin service date (month, day and year)
•
•
Complete individual full name (last name, first name)
Item ordered description: must be narrative description of item
•
ordered (DME vendor may identify by HCPC Code)
Complete full date of birth (month, day, year)
•
•
Length of Time Needed: length of time item will be needed for all
Telephone # (include area code)
durable equipment
•
SERVICING PROVIDER
Quantity ordered: identify quantity ordered; for expendable
•
supplies, designate supplies needed for 1 month; if items are
Complete provider number (10-digit NPI)
•
required greater than 1 month, note time frame in the Length of
Complete provider name
•
Time Needed column (if more than one item is needed but not
Complete contact identifying person to call if DMAS has questions
needed every month then the provider should indicate the
appropriate amount (i.e., 1 per 2 month or 1/2M etc.)
•
Section II
INDIVIDUAL INFORMATION
Frequency of Use, Justification/Comments: practitioner's order
•
for frequency of use must be identified
Check ALL boxes that apply
•
Identify functional limitations related to individual and need for
Section IV
PHYSICIAN CERTIFICATION
DME service
•
•
If requesting oxygen, the results of PO 2 /Saturation levels must be
Physician full name (print)
•
identified
Must be signed and fully dated by physician (NOTE: Attached
•
Date last examined by practitioner
physician prescription will not be accepted in lieu of physician
•
ICD Code (optional)
signature/date on this form);
DME
IF ORDERS FOR
SERVICE ARE
•
Clinical diagnoses - narrative must be identified. Diagnosis must
,
MUST
/
WRITTEN ON BOTH SIDES OF FORM
PHYSICIAN
SIGN
DATE BOTH
be related to the item being requested
SIDES OF FORM
•
•
Check appropriate line for date of on-set
Complete physician Medicaid provider number (optional)
•
Telephone number (include area code)
DMAS-352, Revised 8/2015
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Parent category: Medical