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Certificate Of Medical Necessity Continuation Form CMS-854 - Official Federal Forms
| Certificate Of Medical Necessity Continuation Form Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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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 PATIENT HICN DME 11.02 SECTION C Narrative Description of Equipment and Cost (continued) (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.) SECTION D 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. PHYSICIAN'S SIGNATURE_________________________________________________________________________ DATE _____/_____/_____ Form CMS-854 (09/05) EF 08/2006 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY SECTION C CONTINUATION FORM (CMS-854) SECTION C: NARRATIVE DESCRIPTION OF EQUIPMENT & COST: (To be completed by the supplier) 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. SECTION D: PHYSICIAN ATTESTATION: PHYSICIAN SIGNATURE AND DATE: (To be completed by the physician) 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. 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. Form CMS-854 (09/05) INSTRUCTIONS EF 08/2006 American LegalNet, Inc. www.USCourtForms.com
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