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Click ‘Get Form’ to open the Certificate of Medical Necessity in our editor.
Begin by filling in the provider's name, NPI number, and Medicaid Legacy number at the top of the form.
Enter the consumer's details including their name, sex, date of birth, height, and weight. Specify whether you are requesting a 3-month trial rental or purchase.
In Section A, complete all fields regarding pertinent diagnoses and check 'Yes' or 'No' for each question related to diabetes management and compliance.
If applicable, provide explanations for any 'No' responses in the designated area.
Section B requires documentation of compliance after the trial period. Indicate if the consumer is compliant with pump usage and if there has been an improvement in metabolic control.
Finally, Section C must be completed by the prescriber. Ensure that they print their name, provide their phone number, sign and date the form within 30 days of service.

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