Form Cms-854 - Certificate Of Medical Necessity - Dme 11.02 printable pdf download

Form Cms-854 - Certificate Of Medical Necessity - Dme 11.02

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY

DME 11.02

CMS-854 — CONTINUATION FORM

PATIENT NAME

PATIENT HICN

SECTION C

Narrative Description of Equipment and Cost

(continued)

(1) Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule Allowance for

each item, accessory and option. (see instructions on back.)

SECTION D

PHYSICIAN Attestation and Signature/Date

I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of

Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed

by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I

understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.

PHYSICIAN’S SIGNATURE_________________________________________________________________________ DATE _____/_____/_____

Signature and Date Stamps Are Not Acceptable.

Form CMS-854 (09/05)

Form Cms-854 - Certificate Of Medical Necessity - Dme 11.02