Durable Medical Equipment And Respiratory Medical Gas, Equipment And Supplies Face-To-Face Encounter

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Durable Medical Equipment and Respiratory Medical Gas,
Progress Note
Equipment and Supplies Face-to-Face Encounter
Prog&Orders
____________________________
____________
________________
Patient Name:
Date of Birth:_
MRN#:
Certification Date
I certify that this patient is under my care and that I had a face-to-face encounter that meets the physician face-to-face
encounter requirements with this patient on:
/
/
Medical Condition
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason
for the DME and/or respiratory medical gas, equipment, supplies ordered (list medical condition(s):
Durable Medical Equipment/ Respiratory Medical Gas, Equipment/Supplies Ordered
I spoke to the patient about the need and certify that, based on my findings, the following items are medically necessary:
Clinical Findings/Progress Note
My clinical findings support the need for the above services because:
Community Physician to manage follow-up:
Certification: Based on my findings these above listed items are medically necessary.
Physician's Signature
EMR#
Date
Time
Physician's Printed Name
WR116-020 (7/3/13)
Durable Medical Equipment, Respiratory Medical Gas,
Patient Label
Equipment and Supplies Certification Form
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