Certificate Of Medical Necessity

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M edical Reimbursement Form
Please print this form, have your doctor fill it out, and send it
directly to your insurance provider along with a copy of your
invoice showing product purchase.
Certificate of Medical Necessity
A requirement of your patient's health insurance and/or the Board of Equalization
Patient Name: _______________________ DOB:________________
Prescription Date: _______________
Address & Phone:
Sex: M______ F______
Initial
______
_______________________________
Renewal ______
_______________________________
HIC#:________________
Insurance Company (s):
Policy/Group # (s):
Medical supplies and/or equipment will
#1_______________________________
#1_______________________________
be needed for ______ months from the
#2_______________________________
#2_______________________________
above date.
Related Diagnosis with applicable diagnosis code (s):
____________________________________________________________________________________
____________________________________________________________________________________
Reason supplies and/or equipment is necessary:
____________________________________________________________________________________
____________________________________________________________________________________
Billing Code:
Required Medical Items (if necessary, list additional items on back)
_______________
__________________________________________________________
_______________
__________________________________________________________
_______________
__________________________________________________________
_______________
__________________________________________________________
_______________
__________________________________________________________
Note: Use billing code HCPCS-E1399 Durable Medical Equipment (DME), Miscellaneous.
Prognosis: ____________________
Date last seen PRIOR to this prescription: _______________
Physician's Name: __________________________________
Phone Number: ___________________
Complete Address: ____________________________________________________________________
Medi-Cal Provider #: _______________________ Unique Physician ID Number (UPIN) ______________
Physician's signature: _________________________________________ Date: ____________________

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