Achoo Allergy Certificate Of Medical Necessity

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Medical Reimbursement Form
Print out this form, have your physician fill it out, and send
the signed certificate, along with your product invoice, to
your insurance provider for a possible reimbursement.
Certificate of Medical Necessity
A requirement of your patient’s health insurance and/or Board of Equalization
Patient Name: __________________________________ Date of Birth: ______________ Sex: M □F □
Address: ________________________________________ Telephone: __________________________
Prescription Date: ________________ Renewal □ HIC#: __________________ Initial: ______________
Insurance Company(s) Policy/Group Number(s)
1. _______________________________________ 1. ________________________________________
2. _______________________________________ 2. ________________________________________
Diagnosis Code
Diagnosis (If necessary, list additional items on the back.)
_____________
__________________________________________________________________
_____________
__________________________________________________________________
Reason why products are necessary:
___________________________________________________________________________________
___________________________________________________________________________________
Billing Code Required Medical Items (If necessary, list additional items on the back.)
___________________________________________________________________________________
___________________________________________________________________________________
Note: Use billing code HCPCS-E1399 Durable Medical Equipment (DME), Miscellaneous
Physician’s Name: _________________________________ Telephone: _________________________
Street Address: ______________________________________________________________________
Medi-Cal Provider Number: ___________________ Unique Physician ID Number: _________________
Patient Prognosis: ___________________ Date last seen PRIOR to this prescription: ______________
Physician’s Signature: __________________________________________ Date : __________________
3411 Pierce Dr., Ste. 100, Atlanta, GA 30341 1-800-339-7123

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