COURT COUNTY OFU.S. DEPARTMENT OF HEALTH & HUMAN SERVICESFORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0679 CERTIFICATE OF MEDICAL NECESSITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DMERC 10.02B:::::::Index No.ENTERAL NUTRITIONSECTION ACertification Type/Date:INITIAL //REVISED //RECERTIFICATION //Calendar No.PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBERSUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBERJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)( ) - HICN( ) - NSC #PT DOB //; Sex (M/F) ; HT.(in.) ; WT.(lbs.)PLACE OF SERVICE NAME and ADDRESS of FACILITY if applicable (SeePHYSICIAN NAME, ADDRESS (Printed or Typed) HCPCS CODES:Reverse). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PHYSICIAN'S UPIN: PHYSICIAN'S TELEPHONE #: ( ) - SECTION BInformation in this Section May Not Be Completed by the Supplier of the Items/Supplies.THE PEOPLE OF THE STATE OF NEW YORK TOEST. LENGTH OF NEED (# OF MONTHS): 1-99 (99=LIFETIME)DIAGNOSIS CODES (ICD-9):ANSWERSANSWER QUESTIONS 7, 8, AND 10 -15 FOR ENTERAL NUTRITION(Circle Y for Yes, N for No, or D for Does Not Apply, Unless Otherwise Noted)Questions 1 -6, and 9, reserved for other or future use.GREETINGS:YN7.Does the patient have permanent non-function or disease of the structures that normally permit food to reach or be absorbed from the small bowel?WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableYN8.Does the patient require tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status?,located at County ofA)B)10.Print product name(s).o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomA)B)11.Calories per day for each product?Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.12.Days per week administered? (Enter 1 -7)13.Circle the number for method of administration?12341 -Syringe 2 -Gravity 3 -Pump 4 -Does not apply, one of the Justices of theYND14.Does the patient have a documented allergy or intolerance to semi-synthetic nutrients?Court in Witness, Honorableday of, 20 County,15.Additional information when required by policy:(Attorney must sign above and type name below)NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): NAME:EMPLOYER:TITLE:SECTION CNarrative Description Of Equipment And Cost(1) Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule Allowance for each item, accessory, and option. (See Instructions On Back)Attorney(s) forOffice and P.O. AddressSECTION DPhysician Attestation and Signature/DateTelephone No.: Facsimile No.: E-Mail Address:I certify that I am the 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.//DATEPHYSICIAN'S SIGNATURE(SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)Mobile Tel. No.:CMS-853 (04/96)American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SECTION A:(May be completed by the supplier):::::::Index No.CERTIFICATIONIf this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the spaceTYPE/DATE: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 also indicate the recertification date in the space marked "REVISED." If this is a recertification, indicate the initial date needed in the space marked INITIAL, and also 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 RECERTIFICATION date.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)PATIENTIndicate the patient's name, permanent legal address, telephone number and his/her health insurance claim numberINFORMATION:(HICN) as it appears on his/her Medicare card and on the claim form.SUPPLIERIndicate the name of your company (supplier name), address and telephone number along with the Medicare SupplierINFORMATION:Number assigned to you by the National Supplier Clearinghouse (NSC).PLACE OF SERVICE:Indicate the place in which the item is being used; i.e., patient's home is 12, skilled nursing facility (SNF) is 31, End Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a complete list.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FACILITY NAME:If the place of service is a facility, indicate the name and complete address of the facility.HCPCS CODES:List all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification should not be listed on the CMN.THE PEOPLE OF THE STATE OF NEW YORK TOPATIENT DOB, HEIGHT,Indicate patient's date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested.WEIGHT AND SEX:PHYSICIAN NAME,Indicate the physician's name and complete mailing address.ADDRESS:UPIN:Accurately indicate the ordering physician's Unique Physician Identification Number (UPIN).GREETINGS:PHYSICIAN'SIndicate the telephone number where the physician can be contacted (preferably where records would be accessibleWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court
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