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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Certification Type and Date at the top of the form. Choose between 'Initial' or 'Revised' as applicable.
3. Fill in the patient's details, including their name, address, phone number, and insurance information. Ensure accuracy for seamless processing.
4. Provide the patient's date of birth and sex (M/F), along with their height and weight measurements.
5. Complete the supplier's information, including name, address, phone/fax number, NPI#, and PTAN.
6. Enter physician details similarly, ensuring all contact information is correct.
7. Specify the place of service and include any relevant HCPCS codes for billing purposes.
8. In the detailed narrative section, describe the prescribed item thoroughly. Attach any necessary medical records to support your claims.
9. The physician must establish the length of need in months and provide ICD-10 diagnosis codes that justify medical necessity.
10. Finally, ensure that the physician signs and dates the form to validate its authenticity before submission via fax or email.

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