Nf Peti Medical Necessity Certification Form (Page 2 of 2) in pdf

Nf Peti Medical Necessity Certification Form Page 2

Dental Criteria for NF PETI

Side 2

The nursing facility shall complete the following section regarding prophylaxis ( e.g.

scaling, planing, debridement, routine cleaning and polishing, and related services),

routine dental evaluations and x-rays when submitting a NF PETI request for coverage of

service(s).

A. Has resident had any form of dental prophylaxis in the last 12 months? If yes, give date. ___________

B. Were any of the prophylactic services previously performed, or is the service currently being requested

to be performed by an independent dental hygienist? ____Yes _____ No

C. Has resident had any clinical oral evaluations or radiographs (x-rays) billed as NF PETI during the

calendar year that were paid from the client’s first $400 of NF PETI funds? _____ Yes ____ No

If yes, provide procedure code, date of service, provider name and amount paid.

Attach a copy of the itemized provider bill or treatment plan which includes diagnostic

codes, ADA-CDT procedure codes, tooth numbers included in each procedure and the

cost of each procedure.

Requested NF PETI amount:__________________

I certify that I consider the supplies and/or services included in this request to be medically

necessary and that there are no medical or cognitive contraindications to providing these supplies

and/or services.

Signature of Attending Physician ____________________________ Date _____ License#_____

Signature of Dental Provider ______________________________ Date_____ License#_____

I agree to the purchase of the supplies and/or equipment covered by this request. I understand

that NF PETI may not cover the entire cost.

Signature of Client or Responsible Party ____________________________Relationship______

Incomplete forms shall be returned for completion.

Revised August 2005

Nf Peti Medical Necessity Certification Form Page 2