Get Medical Necessity Form

Filling out the Medical Necessity Form is an essential step in obtaining necessary medical equipment. This guide provides clear, step-by-step instructions to help you complete the form online efficiently.

Follow the steps to complete the Medical Necessity Form online.

1. Click the ‘Get Form’ button to obtain the Medical Necessity Form and open it in your preferred online platform.
2. In Section A, select the type of certification by marking 'INITIAL', 'REVISED', or 'RECERTIFICATION' and enter the appropriate dates.
3. Fill in the patient’s name, address, telephone number, and Health Insurance Claim Number (HICN) as shown on their Medicare card.
4. Provide the supplier's information, including name, address, telephone number, and National Supplier Clearinghouse (NSC) or National Provider Identifier (NPI) number.
5. Indicate the place of service and enter relevant procedure codes for items being ordered.
6. Enter the patient's date of birth, height, weight, and sex as required.
7. Supply the physician's name, address, phone number, and UPIN or NPI number.
8. For Section B, specify the estimated length of need, indicating the number of months required for the item.
9. List relevant diagnosis codes that justify the medical necessity for the item.
10. Answer questions 1-5 regarding the patient's condition by checking ‘Y’ for yes, ‘N’ for no, or ‘D’ for does not apply.
11. If applicable, fill in the name of the person answering Section B questions, including their title and employer.
12. In Section C, provide a narrative description of the equipment, accessory details, supplier charges, and Medicare fee schedule allowances.
13. Section D requires the physician to attest by signing and dating the form after reviewing all preceding sections.

Complete your Medical Necessity Form online today to ensure timely processing.