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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No. 0938-0679 CERTIFICATE OF MEDICAL NECESSITY CMS-854 CONTINUATION FORM PATIENT NAME SECTION C DME 11. PHYSICIAN Attestation and Signature/Date I certify that I am the treating physician identified in Section A of this form. I have received Sections A B and C of the Certificate of Medical Necessity including charges for items ordered. PHYSICIAN S SIGNATURE DATE // Form CMS-854 09/05 EF 08/2006 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY SECTION C CONTINUATION FORM CMS-854 To be completed by the supplier NARRATIVE DESCRIPTION OF EQUIPMENT COST Provide 1 a narrative description of the item s ordered as well as all options accessories 2 the product model and serial number of the product being delivered if applicable 3 the supplier s charge for each item option accessory and 4 the Medicare fee schedule allowance for each item/option/accessory/supply/drug if applicable. 02 PATIENT HICN Narrative Description of Equipment and Cost continued item accessory and option* see instructions on back. Any statement on my letterhead attached hereto has been reviewed and signed by me. I certify that the medical necessity information in Section B is true accurate and complete to the best of my knowledge and I understand that any falsification omission or concealment of material fact in that section may subject me to civil or criminal liability. PHYSICIAN ATTESTATION The physician s signature certifies 1 the CMN which he/she is reviewing includes Sections A B C and D 2 the answers in Section B are correct and 3 the self-identifying information in Section A is correct. AND DATE After completion and/or review by the physician of Sections A B and C the physician must sign and date the CMN in Section D verifying the Attestation appearing in this Section* The physician s signature also certifies the items ordered are medically necessary for this patient According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response including the time to review instructions search existing resources gather the data needed and complete and review the information collection* If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Blvd. Baltimore Maryland 21244. DO NOT SUBMIT CLAIMS TO THIS ADDRESS* Please see http //www. medicare. gov/ for information on claim filing. PHYSICIAN ATTESTATION The physician s signature certifies 1 the CMN which he/she is reviewing includes Sections A B C and D 2 the answers in Section B are correct and 3 the self-identifying information in Section A is correct. AND DATE After completion and/or review by the physician of Sections A B and C the physician must sign and date the CMN in Section D verifying the Attestation appearing in this Section* The physician s signature also certifies the items ordered are medically necessary for this patient According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number. .