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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 ....

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How to fill out the CMS-854 online

The CMS-854 form is a crucial document used for the Certificate of Medical Necessity continuation. This guide provides step-by-step instructions to help users fill out the form accurately and confidently, ensuring all necessary information is included for proper processing.

Follow the steps to complete the CMS-854 form online.

  1. Press the ‘Get Form’ button to access the CMS-854 form and open it in your editor.
  2. In Section C, Narrative Description of Equipment and Cost, provide a clear description of the item(s) and all accessories ordered. Include the product model and serial number if applicable, as well as the supplier’s charge for each item.
  3. Also in Section C, note the Medicare Fee Schedule Allowance for each item, accessory, and option. Ensure that these details are accurate to facilitate processing.
  4. Move to Section D, where the physician must review the completed information. The physician will also need to certify that they are the treating physician as stated in Section A.
  5. In Section D, the physician must sign and date the form, certifying the information's accuracy and the medical necessity of the items ordered.
  6. After ensuring all sections are completed and verified, save your changes, and choose to download, print, or share the CMS-854 form as needed.

Complete your CMS-854 form online today for efficient processing.

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