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Begin with Section A. Indicate the Certification Type and Date by selecting either 'INITIAL' or 'RECERTIFICATION' and filling in the appropriate dates.
Fill in the Patient Information, including their name, address, telephone number, and Health Insurance Claim Number (HICN).
Provide Supplier Information by entering your company name, address, telephone number, and National Provider Identification (NPI) number.
In Section B, estimate the length of need for the device in months and list relevant Diagnosis Codes (ICD-9) that justify medical necessity.
Answer questions 1–10 regarding the patient's condition and treatment history. Ensure accuracy as this section may require physician review.
Complete Section C with a narrative description of equipment ordered along with costs. This should be detailed for clarity.
Finally, Section D requires the physician's signature and date to certify that all information is accurate and complete.

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