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CERTIFICATE OF MEDICAL NECESSITY DURABLE MEDICAL EQUIPMENT

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All of the following information is required in order for medical equipment to be covered. This form must be contained in the recipient's clinical records. RECIPIENT NAME:______________________________________________________________________________________ MEDICAL ASSISTANCE ID NUMBER: ___________________________________________________________________ ****************************************************************************************************************** DIAGNOSIS - INCLUDING AN EXPLANATION OF THE PARTICULAR PROBLEM RESULTING FROM THE DIAGNOSIS WHICH RELATES TO THIS EQUIPMENT REQUEST: (an example of this requirement would be a diagnosis of cerebral palsy - problem being unable to ambulate and wheelchair bound)

PROGNOSIS: HOW LONG IS THIS PROBLEM EXPECTED TO LAST? MONTHS_________________________________________ INDEFINITELY PERMANENTLY EXPLANATION OF THE MEDICAL NECESSITY/JUSTIFICATION FOR CONTINUED RENTAL:

EQUIPMENT BEING PRESCRIBED:

PHYSICIAN'S SIGNATURE: _________________________________________________ DATE: ____________________ ****************************************************************************************************************** EXPLANATION OF THE EQUIPMENT'S FUNCTION: (to include identifying information such as brochures and pictures)

PROCEDURE CODE(S):

$_________________________________________ $____________________________________________________________ Purchase Price Rental Price (per day-week-month-other) DME PROVIDER NAME: ________________________________________________________________________________ DME PROVIDER ADDRESS: DME PROVIDER IDENTIFICATION NUMBER: ____________________________________________________________ DME CONTACT PERSON NAME: ________________________________________________________________________ DME CONTACT PERSON PHONE NUMBER: ____________________________________________________________ DME CONTACT PERSON FAX NUMBER: ________________________________________________________________

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