Certificate Of Medical Necessity Durable Medical Equipment And Supplies Template

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VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
CERTIFICATE OF MEDICAL NECESSITY
DURABLE MEDICAL EQUIPMENT AND SUPPLIES
RECIPIENT DATA
SERVICING PROVIDER
SECTION I
I.D.#
I.D.#
Name
Name
D.O.B
Contact Person
Phone #
Phone #
RECIPIENT INFORMATION
SECTION II
Answer all questions that are applicable to DME service being requested.
DESCRIPTION/ADDITIONAL INFORMATION
If answer is yes, you must describe/attach additional information.
(Additional space on reverse)
Does patient:
YES
NO
1. have impaired mobility?
2. have impaired endurance?
3. have restricted activity?
4. have skin breakdown? (Describe site, size,
depth and drainage)
5. have impaired respiration? (Identify most
recent PO2__________/Saturation level__________
for patients on oxygen)
6. require assistance with ADL's?
7. have impaired speech?
*** 8. a) require nutritional supplements? (If yes,
answer b and c below.)
b) sole source or primary source (circle one)
c) height__________ weight__________
IS THE ITEM SUITABLE FOR USE IN HOME, AND DOES THE PATIENT/CAREGIVER DEMONSTRATE WILLINGNESS/ABILITY TO USE THE EQUIPMENT? YES____ NO____
*** DATE PATIENT LAST EXAMINED BY PRACTITIONER ***
(required)
MM
DD
YY
ICD9 Code
Clinical Diagnoses
Date of Onset
Less than 6 months
Greater than 6 months
SECTION III
(ADDITIONAL SPACE ON REVERSE)
Length
Begin
Quantity
HCPCS
Item Ordered
Frequency of Use*
of
Service
Ordered/
Time
Code
Description*
Justification/Comments
Date
x1 Month*
Needed
PRACTITIONER CERTIFICATION
SECTION IV
(MUST BE SIGNED AND DATED BY PRACTITIONER)
I CERTIFY THAT THE ORDERED DME AND SUPPLIES ARE PART OF MY TREATMENT PLAN AND, IN MY OPINION, ARE MEDICALLY NECESSARY.
ORDERING PRACTITIONER'S NAME (print)
PRACTITIONER'S SIGNATURE*
DATE
I.D.#
PHONE
*Required fields. If any of these fields are blank the CMN is not valid.
**Practitioner will be a physician and a nurse practitioner.
Issuance of a PA does not guautentee payment. Payment is contingent upon all appropriate documentation being readily available for review.
DMAS-352, Revised 7/2010

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