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Get CMS-484 2011

Ment of material fact in that section may subject me to civil or criminal liability. PHYSICIAN’S SIGNATURE Signature and Date Stamps Are Not Acceptable. Form CMS-484 (11/11) DATE / / 1 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR OXYGEN SECTION A: (May be completed by the supplier) CERTIFICATION DATE: If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space TYPE/marked “INITIAL.” If this is .

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