Get Initial //

Filling out the INITIAL // form is essential for registering medical necessity for manual wheelchairs. This guide will provide clear and detailed instructions to ensure a smooth and accurate filling process.

Follow the steps to complete the INITIAL // form online.

1. Click 'Get Form' button to access the INITIAL // form and open it for completion.
2. In Section A, fill in the certification type and date. If this is the first request for medical necessity, mark the INITIAL option and enter the relevant date.
3. Provide the patient’s complete information, including name, address, telephone number, and health insurance claim number (HICN), ensuring accuracy.
4. Enter the supplier's details in the designated fields, including your company name, address, telephone number, and National Supplier Clearinghouse (NSC) number.
5. Specify the place of service where the wheelchair will be used. Select the appropriate code according to the service location.
6. List all HCPCS procedure codes for items ordered that require a Certificate of Medical Necessity (CMN) in the designated area.
7. Complete the patient details section with their date of birth, height, weight, and sex.
8. Provide the physician's information, including name, address, and Unique Physician Identification Number (UPIN). Also, include contact telephone number for clarification if necessary.
9. In Section B, provide the estimated length of need for the wheelchair, using a number from 1 to 99, and enter relevant diagnosis codes (ICD-9) that pertain to the patient’s condition.
10. Answer the questions regarding the medical necessity for the wheelchair base and any accessories, marking ‘Y’ for Yes, ‘N’ for No, or ‘D’ for Does Not Apply as appropriate.
11. If Section B is completed by someone other than the physician, include their name, title, and employer information.
12. In Section C, provide a detailed narrative description of all items ordered, including costs and Medicare fee schedule allowances for each item.
13. Section D must be signed and dated by the physician to certify that all information is accurate and truthful regarding the medical necessity.

Complete your documentation online to ensure timely processing of your request.