U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION FORM APPROVED OMB NO. 0938-0679 CERTIFICATE OF MEDICAL NECESSITY DMERC 02.03B MANUAL WHEELCHAIRS SECTION A Certification.
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How to fill out the Dmerc 02 03b online
The Dmerc 02 03b form, known as the certificate of medical necessity for manual wheelchairs, is essential for documenting the medical need for patients requiring mobility assistance. This guide will provide clear, step-by-step instructions to help you accurately complete this form online.
Follow the steps to fill out the Dmerc 02 03b form easily.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In Section A, indicate the type of certification (initial or revised) by filling in the date. Provide the patient's name, address, telephone number, and HIC number as it appears on their Medicare card. Similarly, fill out the supplier's name, address, telephone number, and NSC number.
- Specify the place of service where the wheelchair will be used, and if applicable, include the name and address of the facility. Enter the patient’s date of birth, sex, height, and weight in the indicated fields.
- Under Section B, enter the estimated length of need, followed by the diagnosis codes (ICD-9) related to the medical necessity for the wheelchair. Respond to questions regarding the manual wheelchair base and accessories by circling 'Y' for yes, 'N' for no, or 'D' for does not apply.
- In Section C, provide a narrative description of all items being ordered, including accessories and options. Include the supplier's charge and the Medicare fee schedule allowance for each item.
- Section D requires the physician's attestation. The physician must review the completed sections and provide their signature and date to certify that the information is true and accurate.
- After completing the form, you can save changes, download, print, or share the Dmerc 02 03b form according to your needs.
Start filling out the Dmerc 02 03b form online now to ensure timely processing of medical necessity claims.
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