Certificate of Medical Necessity (CMN) and DME Information 2025

1. Click ‘Get Form’ to open the Certificate of Medical Necessity in our editor.
2. Begin by filling out the Certification Type/Date section. Select whether this is an Initial, Revised, or Recertification request.
3. Enter the patient's information including their name, address, telephone number, and insurance details in the designated fields.
4. Complete the Supplier section with your name, address, phone/fax number, NPI#, and PTAN. Ensure all details are accurate for processing.
5. Provide the patient's date of birth, sex, height, and weight as required in the respective fields.
6. Fill in the Physician's information including their name, address, phone/fax number, and NPI#.
7. Specify the Place of Service and include any applicable facility details.
8. Input HCPCS codes and a detailed narrative description of the item prescribed by the physician. Attach any necessary medical records for support.
9. Indicate the established length of need in months and provide ICD-10 diagnosis codes that justify medical necessity.
10. Finally, ensure that the physician attests to their signature and date before submitting via fax or email as indicated at the bottom of the form.

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