Form Map 1000b - Certificate Of Medical Necessity - Department For Medicaid Services

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MAP-1000B Rev. 7/10
CERTIFICATE OF MEDICAL NECESSITY
Cabinet for Health & Family Services
Department for Medicaid Services
Metabolic Formulas and Foods
Section A
Section A
Section B
Section B
Recipient Name: _____________________________
Recipient Name: _____________________________
Provider Name: ____________________________
Provider Name: ____________________________
Member #:_____________________________
MAID Number: _____________________________
Provider Number: __________________________
Provider Number: __________________________
Recipient Address: ___________________________
Recipient Address: ___________________________
Provider Address: __________________________
Provider NPI:
___________________________
___________________________________________
___________________________________________
_________________________________________
Provider Address: __________________________
___________________________________________
___________________________________________
_________________________________________
_________________________________________
Phone Number: _____________________________
Phone Number: _____________________________
Phone Number: ____________________________
_________________________________________
Date of Birth: _______________________________
Date of Birth: _______________________________
Fax Number: ______________________________
Phone Number: ____________________________
Fax Number:
Section C Product
Section C Product
Section D
Section D
prescribed:_________________________________
prescribed:_________________________________
Prescriber Name: ___________________________
Prescriber Name: ___________________________
___________________________________________
___________________________________________
Prescriber Address: _________________________
Prescriber Number:_________________________
___________________________________________
___________________________________________
_________________________________________
Prescriber NPI: ____________________________
___________________________________________
___________________________________________
_________________________________________
Prescriber Address: _________________________
___________________________________________
___________________________________________
Prescriber KY Medicaid Number: _____________
_________________________________________
___________________________________________
___________________________________________
NPI: ______________________
_________________________________________
___________________________________________
___________________________________________
Phone Number: ____________________________
Phone Number: ____________________________
___________________________________________
___________________________________________
Fax Number: ______________________________
Fax Number: ______________________________
Areas below must be completed by prescriber and not the supplier of the equipment/supply ordered.
Areas below must be completed by prescriber and not the supplier of the equipment/supply ordered.
Section E
Section E
Date of Request: _________________________________
Date of Request: _________________________________
Initial CMN Request: ____________ Date Last Seen by Prescriber: _______________
Initial CMN Request: ____________ Date Last Seen by Prescriber: _______________
Section F Primary Diagnosis: (Check applicable)
Section F Primary Diagnosis: (Check applicable)
____Phenylketonuria____Hyperphenylalaninemia____Tyrosinemia (Types I, II, III)____
____Phenylketonuria____Hyperphenylalaninemia____Tyrosinemia (Types I, II, III)
____Branched-chain Amino-Acid Disturbance,specify:_______________________________________
____Branched-chain Amino-Acid Disturbance,specify:_______________________________________
____Urea Cycle Disorder, specify:_______________________________________________________
____Urea Cycle Disorder, specify:_______________________________________________________
____Methylmalonic acidemia
____Methylmalonic acidemia
____Other, please specify:___________________________________________________________________
____Other, please specify:___________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Section G Pertinent medical history, diagnostic tests, treatment plan.
Section G Pertinent medical history, diagnostic tests, treatment plan.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
How often will the client be seen?______Date therapy initiated: _____________________________________
How often will the client be seen?______Date therapy initiated: _____________________________________
Section H
Section H
I certify that I am the prescriber identified in Section A of this form. I have received Sections A, B, C, and D of the Certificate of Medical
I certify that I am the prescriber identified in Section A of this form. I have received Sections A, B, C, and D of the Certificate of Medical
Necessity (including charges for items ordered). I certify that I or my medical staff has completed Sections E, F, and G. This CMN and
Necessity (including charges for items ordered). I certify that I or my medical staff has completed Sections E, F, and G. This CMN and
any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in
any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in
Section E, F, and G is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or
Section E, F, and G 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.
concealment of material fact in that section may subject me to civil or criminal liability.
Physician’s printed
Physician’s printed
name:_______________________________Signature:_____________________________________________________
name:_______________________________Signature:_____________________________________________________
Date signed:_______________________________(Signature and date stamps are not acceptable.)
Date signed:_______________________________(Signature and date stamps are not acceptable.)

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