Form 15-509 - Certificate Of Medical Necessity Page 2

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Section 2 – Medical Necessity Information
Itemization of items and charges for each (attach an additional sheet if necessary):
Section 3 – Physician Attestation and Signature
I certify that I am the physician identified in section 1C of this form. I certify that the medical necessity information is
true, accurate and complete, to the best of my knowledge.
Your signature required
Physician’s Signature (Signature and date stamps are not acceptable)
Date Signed
Page 2

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