DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
CMS-849 — SEAT LIFT MECHANISMS
Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE______________
PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable
if applicable (see reverse)
NPI NUMBER or UPIN
(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
Information in this Section May Not Be Completed by the Supplier of the Items/Supplies.
EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME)
DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______
ANSWER QUESTIONS 1-5 FOR SEAT LIFT MECHANISM
(Circle Y for Yes, N for No, or D for Does Not Apply)
1. Does the patient have severe arthritis of the hip or knee?
2. Does the patient have a severe neuromuscular disease?
3. Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home?
4. Once standing, does the patient have the ability to ambulate?
5. Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position
(e.g., medication, physical therapy) been tried and failed? If YES, this is documented in the patient's medical records.
NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):
NAME: ____________________________________________TITLE: ________________________EMPLOYER:__________________________
Narrative Description of Equipment and Cost
(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)
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 _____/_____/_____
Form CMS-849 (09/05) EF 08/2006