U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
OMB NO. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN ____________________________
(__ __ __) __ __ __ - __ __ __ __ NSC # __________________________________
PT DOB ____/____/____; Sex ____ (M/F) ;
PLACE OF SERVICE ________
NAME and ADDRESS of FACILITY if applicable (See
PHYSICIAN NAME, ADDRESS (Printed or Typed)
PHYSICIAN'S UPIN: ______________________________
PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __
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 12 AND 14 FOR CPAP
for No, or
for Does Not Apply, Unless Otherwise Noted)
Questions 1 - 11, and 13, reserved for other or future use.
12. How many episodes of apnea lasting greater than 10 seconds does the patient have during 6-7 hours of recorded sleep?
(Number of episodes) (If greater than 99, enter 99.)
14. Does the patient have obstructive sleep apnea?
NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):
NAME: ____________________________________________ TITLE: ________________________
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)
Physician Attestation and Signature/Date
I certify that I am the 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)
FORM HCFA 845 (4/96)