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Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

FORM APPROVED

HEALTH CARE FINANCING ADMINISTRATION

OMB NO. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY

DMERC 03.02

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

SECTION A

Certification Type/Date:

INITIAL ___/___/___

REVISED ___/___/___

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

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

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

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

HT.______(in.) ;

WT._____(lbs.)

PLACE OF SERVICE ________

HCPCS CODE

NAME and ADDRESS of FACILITY if applicable (See

PHYSICIAN NAME, ADDRESS (Printed or Typed)

Reverse)

PHYSICIAN'S UPIN: ______________________________

PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __

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): _________ _________ _________ _________

ANSWERS

ANSWER QUESTIONS 12 AND 14 FOR CPAP

(Circle

for Yes,

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: ________________________

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)

SECTION D

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)