Certificate Of Medical Necessity (Cmn) For Transcutaneous Electrical Nerve Stimulator (Tens) printable pdf download

Certificate Of Medical Necessity (Cmn) For Transcutaneous Electrical Nerve Stimulator (Tens)

DMEnsion

P.O. Box 81460, Rochester, MI 48308-1460

Telephone: (877) 345-4774 Fax: (248) 844-8614

Date:

Requestor:

To:

Fax Number:

Patient Name:

I.D. Number:

Certificate of Medical Necessity (CMN) for Transcutaneous Electrical Nerve

Stimulator (TENS)

Please answer all of the questions listed below for TENS unit

Y for Yes

N for No

D for Does Not Apply

1. Does the patient have acute post-operative pain?

2. What is the date of surgery resulting in acute post-operative pain?

___________________

3. Does the patient have chronic, intractable pain?

If yes, please describe the type of chronic, intractable pain?

_____________________________________________________________________________________

4. How long has the patient had intractable pain? (Enter number of months)

___________________

5. What other treatment modalities have been tried and failed?

_____________________________________________________________________________________

Estimated Length of Need (in months): ________

Clinical

Rationale_____________________________________________________________________

______________________________________________________________________________

____________________________________________________________

Contact Name:________________________

Phone Number: _________________

_________________________

______/______/_____

Physician Signature

Date

(Stamps are not acceptable)

Rev 04/08

Certificate Of Medical Necessity (Cmn) For Transcutaneous Electrical Nerve Stimulator (Tens)