Follow the steps to complete the Pneumatic Compression Device Cmn Form online.

1. Press the ‘Get Form’ button to access the Pneumatic Compression Device CMN Form and open it for editing.
2. In Section A, indicate the type of certification needed by selecting 'INITIAL', 'REVISED', or 'RECERTIFICATION', and fill in the respective dates.
3. Enter the patient's name, permanent address, telephone number, and health insurance claim number (HICN) as it appears on their Medicare card.
4. Provide the supplier's name, address, telephone number, and either the National Supplier Clearinghouse (NSC) or National Provider Identifier (NPI) number.
5. Indicate the place of service where the device will be used, such as the patient’s home or a facility.
6. Fill in the HCPCS code for the requested items and enter the patient's date of birth, height, weight, and sex.
7. Provide the physician's name, address, telephone number, and their applicable NPI or UPIN number.
8. In Section B, estimate the length of time (in months) the patient will require the device, noting '99' for lifetime.
9. Enter the necessary diagnosis codes (ICD-9) that support the medical need for the device.
10. Answer the clinical questions regarding the patient's condition by circling 'Y' for yes or 'N' for no.
11. If someone other than the physician answers Section B, they must print their name, title, and employer.
12. In Section C, provide a narrative description of the required equipment, including any costs and the Medicare fee schedule allowance.
13. In Section D, the treating physician must review the form and attest by signing and dating this section.
14. After all sections are completed, save changes, download, print, or share the form as necessary.

Start completing the Pneumatic Compression Device Cmn Form online today!