Neighborhood Health Plan Certificate Of Medical Necessity Prior Authorization Form Page 2

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Certificate of Medical Necessity
Prior Authorization
Form
Page 2 of 2
Is this equipment replacing a similar piece of equipment?
Yes
No
If yes, please justify
Rent or Purchased
List current equipment in member’s home*
*If this is new equipment, please detail why this equipment & accessories are medically needed.
PLEASE INCLUDE ANY AVAILABLE PICTURES, BROCHURES, SPECIFICATIONS.
Place where equipment will be used
home
work
school
other
Has equipment been tried for accessibility and appropriateness?
Yes
No
If no, explain
How will changes in height and weight affect this equipment?
Current Schedule and Location of Therapies
School based
Outpatient
Early Intervention
Physical Therapy
Daily
Weekly
Monthly
Other
School based
Outpatient
Early Intervention
Occupational Therapy
Daily
Weekly
Monthly
Other
School based
Outpatient
Early Intervention
Speech Therapy
Daily
Weekly
Monthly
Other
NOTE: THIS FORM MUST BE SIGNED BY A PHYSICIAN
Signature of Treating Physician:
Date:
NEIGHBORHOOD DECISION
Authorization is not a guarantee of payment.
Authorization #:
Dates of Service:
Services Approved:
UM Initials:
Notification Date:
Not Approved - Letter to Follow
Neighborhood Health Plan of Rhode Island
●
●
●
910 Douglas Pike
Smithfield, RI 02917
Tel. 401-459-6060
Fax 401-459-6023
Updated 7/2011, 7/2012, Reviewed 6/2013, 2/2016

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