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Get CMS-849 2019-2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No. 0938-0679 CERTIFICATE OF MEDICAL NECESSITY CMS-849 SEAT LIFT MECHANISMS SECTION A DME 07. PHYSICIAN S SIGNATURE DATE // Form CMS-849 09/05 EF 08/2006 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR SEAT LIFT MECHANISMS CMS-849 May be completed by the supplier CERTIFICATION TYPE/DATE If this is an initial certification for this patient indicate this by placing date MM/DD/YY needed initially in the space marked INITIAL. If this is a revised certification to be completed when the physician changes the order based on the patient s changing clinical needs indicate the initial date needed in the space marked INITIAL and indicate the recertification date in the space marked REVISED. 03A Certification Type/Date INITIAL // REVISED // RECERTIFICATION// PATIENT NAME ADDRESS TELEPHONE and HIC NUMBER SUPPLIER NAME ADDRESS TELEPHONE and NSC or applicable NPI NUMBER/LEGACY NUMBER - HICN PLACE OF SERVICE NAME and ADDRESS of FACILITY if applicable see reverse HCPCS CODE PHYSICIAN NAME ADDRESS TELEPHONE and applicable NPI NUMBER or UPIN Information in this Section May Not Be Completed by the Supplier of the Items/Supplies. EST. LENGTH OF NEED OF MONTHS 1-99 99 LIFETIME ANSWERS PT DOB // Sex M/F Ht. in Wt lbs. DIAGNOSIS CODES ICD-9 ANSWER QUESTIONS 1-5 FOR SEAT LIFT MECHANISM Circle Y for Yes N for No or D for Does Not Apply Y N D 1. Does the patient have severe arthritis of the hip or knee 3. Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home 4. Once standing does the patient have the ability to ambulate 5. Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position e*g* medication physical therapy been tried and failed If YES this is documented in the patient s medical records. NAME OF PERSON ANSWERING SECTION B QUESTIONS IF OTHER THAN PHYSICIAN Please Print NAME TITLE EMPLOYER Narrative Description of Equipment and Cost item accessory and option* see instructions on back 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. 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. If this is a recertification indicate the initial date needed in the space marked INITIAL and indicate the recertification date in the space marked RECERTIFICATION* Whether submitting a REVISED or a RECERTIFIED CMN be sure to always furnish the INITIAL date as well as the REVISED or PATIENT INFORMATION Indicate the patient s name permanent legal address telephone number and his/her health insurance claim number HICN as it appears on his/her Medicare card and on the claim form* SUPPLIER Indicate the name of your company supplier name address and telephone number along with the Medicare Supplier Number assigned to you by the National Supplier Clearinghouse NSC or applicable National Provider Identifier NPI.

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